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THE  DISEASES 


OF 


INFANCY  AND  CHILDHOOD. 


DESIGNED  FOR  THE  USE  OF 


STUDENTS  AND  PRACTITIONERS  OF  MEDICINE. 


BY 

HENRY  KOPLIK,  M.D, 

ATTENDING  PHYSICIAN    TO    THE    MOUNT    SINAI    HOSPITAL;    CONSULTING  PHYSICIAN  TO  THE  HOSPITAL 

FOR  DEFORMITIES,  FORMERLY  ATTENDING  PHYSICIAN  TO  THE  GOOD  SAMARITAN  DISPENSARY, 

THE  ST.  JOHN'S    GUILD    HOSPITALS,   NEW    YORK  ;     EX-PRESIDENT  OF    THE  AMERICAN 

PEDIATRIC  SOCIETY  ;    MEMBER  OF  THE  ASSOCIATION  OF  AMERICAN  PHYSICIANS, 

AND  OF  THE  NEW  YORK  ACADEMY  OF  MEDICINE. 


THIRD  EDITION,  REVISED  AND  ENLARGED. 


ILLUSTRATED  WITH  204  ENGRAVINGS  AND  39   PLATES  IN 
COLOR  AND  MONOCHROME 


LEA  &  FEBIGER, 
NEW  YOEK   AND   PHILADELPHIA. 


\\jLA^:iJU.^^i&^ 


Entered  according  to  Act  of  Congress,  in  the  year  1910,  by 

LEA   &   FEBIGER, 

In  the  Office  of  the  Librarian  of  Congress.    All  rights  reserved 


THIS   WORK 
IS    INSCRIBED    TO    MY    PRECEPTORS, 

FRAISrCTS   DEL  AFIELD,  M.D.,  LL.D., 

EMERITUS  PROFESSOR  OF  THE  PRACTICE  OF  MEDICINE  IN  THE  COLLEGE  OF 
PHYSICIANS  AND  SURGEONS,   COLUMBIA  UNIVERSITY,   NEW  YORK, 

AND 

MATHEW  D.  MANN,  M.D., 

PROFESSOR  OF  OBSTETRICS  AND  GYNJ5C0L0GY  IN  THE  UNIVERSITY 
OF  BUFFALO,   NEW  YORK 


Digitized  by  the  Internet  Arcinive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/diseasesofinfancOOkopl 


PREFACE  TO  THE  THIRD  EDITION. 


The  preparation  of  a  third  edition  of  this  work  has  brought  the 
opportunity  to  revise  it  as  well  as  to  introduce  new  matter.  The 
advances  in  our  knowledge  of  the  special  pathology,  diagnosis  and 
treatment  of  the  most  important  diseases  of  infancy  and  childhood 
during  the  past  three  years  have  been  such  as  to  add  materially  to 
our  understanding  of  many  obscure  problems  in  Pediatrics.  I  have 
therefore  in  the  light  of  these  advances  and  my  own  accumulating 
experience  added  to  or  recast  many  chapters  of  this  work.  In  the 
technic  of  treatment  and  diagnosis  of  the  infectious  diseases  the 
reader  will  find  much  that  is  new  and  yet  well  tried  in  practice. 
Infant  feeding,  which  has  advanced  as  to  our  understanding  of  cer- 
tain disturbances  of  nutrition,  has  been  carefully  revised ;  the  diseases 
of  the  stomach,  and  those  of  the  nervous  system,  such  as  cerebral 
palsies,  encephalitis,  poliomyelitis,  tetany,  amaurotic  idiocy,  have 
been  recast.  The  chapters  on  cystitis  and  pyelitis  have  also  been 
brought  up  to  date ;  and  chapters  have  been  added  on  idiocy,  dwarf- 
ism, neurotic  conditions  which  will  be  found  to  be  of  value  to  the 
practitioner.  The  illustrations  have  been  enriched  by  carefully  exe- 
cuted drawings  of  my  own  cases  for  the  most  part  and  those  of 
patients  in  institutions  with  which  I  am  connected.  I  wish  to  thank 
my  colleagues,  Drs.  E.  Lee  Meierhof,  Curtis  C.  Eves,  and  G.  S. 
Dixon,  for  their  kind  cooperation  in  preparing  the  illustrations  for 
the  chapters  on  adenoids  and  the  examination  of  the  ear;  and  also 
Dr.  Henry  Frauenthal,  for  illustrations  of  cases  of  poliomyelitis  and 
cerebral  palsies.  To  my  publishers  thanks  are  due  for  their  uniform 
courtesy  and  encouragement. 

The  Atjthok. 

30  East  Sixty-second  Street, 
New  York,  1910. 


CONTENTS. 


SECTIO^^  I. 

INFANCY  AND  CHILDHOOD. 

PAGE. 

Definition — Infancy — Childhood — Newborn.  Morbidity  in  newborn — In  child- 
hood. Mortality,  in  large  cities,  in  various  diseases — Statistics.  Sudden 
death  among  infants  and  children — Premature  birth.  Circulatory  disturb- 
ances as  causal  factors — Diseases  of  the  respiratory  tract,  affections  of 
the  central  nervous  system,  other  causes.  Surgical  causes,  lymphatism. 
The  normal  infant  and  child,  body  weight — Length  of  body,  head — -Eespir- 
atory  functions,  shape  of  chest,  chest  circumference,  normal  number  of 
respirations,  chemism  of  respiration.  Circulation  and  pulse — Table  of 
average  height,  weight,  head  circumference  and  chest  measurements  of 
American  children.  Pulse  rapidity,  rhythm.  Body  temperature — Urine — 
Physical  characters,  urea,  albumin,  indican,  acetone,  diacetic  acid,  uro- 
bilin, dextrose,  casts,  uric  acid  infarctions.  Mental  and  physical  develop- 
ment of  the  infant — sight,  hearing,  taste,  feelings  of  pleasure — power  to 
hold  the  head  upright — Standing,  crawling,  walking,  laughing,  kissing — - 
Memory,  speech.  Methods  of  examination — History  taking.  Maternal 
history,  parental  history,  onset  of  illness.  Status  prassens,  the  skin,  head, 
face,  respiration,  heart,  facial  palsy,  nuclear  palsy,  Basedow's  disease, 
hydrocephalus,  rachitis,  exhausting  diseases,  congenital  syphilis,  palpebral 
fissure,  sight,  photophobia,  nystagmus.  The  chest — position  of  the  patient. 
Instruments  used,  methods,  inspection,  palpation,  percussion,  auscultation. 
The  abdomen,  inspection,  peritonitis,  free  fluid,  tumors,  palpation,  ascites, 
tympanites,  pain.  Eectal  exploration,  the  joints,  motility,  joint  crepitus. 
The  spine  anatomy,  method  of  examination.  Muscular  apparatus  and 
nervous  system,  reflexes,  patellar  reflex,  Babinski's  reflex,  Kernig's  symp- 
tom. Gait,  walk,  ataxia,  cerebellar  gait,  spastic  walk,  limping  gait,  infan- 
tile paralysis.  Management  and  hygiene  of  the  normal  infant.  Taking 
the  infant  from  the  mother  at  birth.  Tying  of  the  cord,  care  of  the  cord, 
bathing — the  first  bath,  daily  bath,  hardening.  Eyes,  care  of.  Method 
of  taking  temperature.  Diapers,  care  of  the  genitals.  Play,  fondling. 
Sleep — Bed — Nursery — Open  air  exercise.  Clothing,  body  binder.  Skin. 
Mouth — Administration  of  drugs  and  other  methods  of  therapy.  Medic- 
inal treatment,  antipyretics,  dosage,  hypodermic  medication,  hydrotherapy, 
sponge  bath,  cold  chest  compress,  cold  pack,  full  bath,  hypodermoclysis, 
syringing  the  nose,  instruments  and  methods.  Vapor  spray,  calomel  inha- 
lations, stomach  washing,  indications,  method,  gavage.  Eectal  enemata, 
irrigation,  enteroclysis.  Lumbar  puncture,  normal  cerebrospinal  fluid, 
abnormal  conditions,  specific  gravity,  gross  appearances,  tuberculous  men- 
ingitis, suppurative  meningitis,  epidemic  meningitis,  chronic  hydroceph- 
alus, brain  tumors,  sediment,  cytology,  pressure,  operation  of  lumbar 
puncture,  indications,  place,  method,  dangers  of  lumbar  puncture.  The 
introduction  of  sera  and  drugs  into  the  spinal  canal 17-80 


VHl  CONTENTS. 

SECTIOIsT  II. 

NUTEITION  AND  INFANT  FEEDING. 

PAGE. 

Principles  underlying  the  processes  of  nutrition,  water,  mineral  salts,  proteids, 
fats,  carbohydrates.  Metabolism  in  the  nursing  infant,  mineral  salts, 
excreta,  water,  carbonic  acid  gas.  Metabolism  in  the  bottle-fed  infant. 
Caloric  needs  in  breast-  and  bottle-fed  infants.  The  food  of  the  infant, 
human  breast  milk,  colostrum,  physical  properties,  composition,  milk 
appearance  in  breast,  composition,  proteids,  fats,  mineral  salts,  reactions, 
specific  gravity,  bacteria  in  breast  milk,  enzymes  and  alexins  of  breast 
milk,  amount  of  breast  milk  consumed  in  twenty-four  hours,  changes  in 
the  composition  of  breast  milk,  influence  of  foods  on  breast  milk,  drugs 
and  foreign  substances  in  the  milk,  bacteria  in  the  infectious  diseases  in 
breast  milk,  toxins,  antitoxins  and  agglutinins.  Menstruation,  pregnancy. 
Methods  of  analysis  of  breast  milk,  specific  gravity,  Conrad's  method, 
fats,  Lewi's  method,  the  proteids.  Cows'  milk,  composition,  fat,  proteids, 
bacteria  in  cows '  milk,  infected  cows '  milk  as  a  cause  of  epidemics,  typhoid 
fever,  dysentery,  diphtheria,  scarlet  fever,  cholera,  tuberculosis.  Milk 
acidity,  pasteurization,  sterilization,  disadvantages,  assimilation  of  raw, 
pasteurized  and  sterilized  milk.  Attitude  of  the  physician  in  regard  to 
pasteurization  and  sterilization.  Eaw  milk  in  infant  feeding,  frozen  milk, 
nursing  bottles.  Food  preparations,  peptonized  milk,  condensed  milk, 
barley  water,  oatmeal  gruel,  arrowroot  gruel,  beef  juice,  peptone  prepa- 
rations, butter  milk,  beef  extracts,  kumyss,  beef  broth,  acorn  cocoa. 
Artificial  infant  foods — composition,  table  of,  classification.  Maternal 
nursing,  contra-indications  to  maternal  nursing.  Selection  of  a  wet- 
nurse.  Quantity  of  milk  in  breasts,  beginning  of  nursing.  Care  of 
breasts,  fissured  nipples,  caking  of  breasts,  nursing  the  infant,  signs  of 
efficient  nursing,  inefficient  nursing.  Mixed  feeding — method  of  establish- 
ing. Artificial  feeding  of  infants,  the  food.  Biedert's  mixture,  Meig's 
mixture,  Eotch  method,  percentage  feeding,  principles,  proteids,  fats, 
sugar,  water,  salts,  number  of  feedings  necessary  and  quantity  of  each 
nursing,  tables,  household  modification  of  milk  for  infant  feeding,  method 
of.  Top  milks — Twelve  per  cent.,  seven  per  cent,  fat  milk.  Top  milk 
at  home,  home  preparation  of  modified  milk,  method  of  calculating  per- 
centages, problems,  construction  of  formulae.  Too  high  fats  and  remedies, 
diluents,  reaction.  "When  is  a  bottle-fed  infant  thriving?  Table  of  feed- 
ings— Spitting,  colic,  fat  diarrhoea,  greenish  movements,  disturbances  on 
border  line  of  normal  and  abnormal — Vomiting,  low  proteids,  low  fats, 
assimilation  without  increase  of  weight.  When  to  peptonize  food.  Whey 
method  of  milk  modification.  The  use  of  infant  foods — Barley  gruels, 
utilization — Dextrinized  gruels.  Food  after  the  sixth  month.  Feeding 
from  the  ninth  to  the  twelfth  month — weaning.  Feeding  from  the  twelfth 
to  the  eighteenth  month.  Feeding  from  the  eighteenth  month  to  the  end 
of  the  second  year.  Feeding  from  the  third  to  the  sixth  year  and  after. 
Feeding  of  sick  infants  and  children 81-164 


CONTENTS.  X 

SECTIOIsT  III. 

DISEASES  OF  THE  NEWBOEN. 

PAGE. 

Physiology  of  the  newborn^ — Eespiration — Circulation — Pulse — Blood — Diges- 
tive functions — Body  temperature — Skin — Breasts — Urine — Eectal  excreta 
— Nervous  system — Metabolism — Excretion  and  waste.  Mortality  and 
sudden  death  in  the  newborn.  Congenital  anomalies — -Of  the  scrotum — 
Testes — Hydrocele  congenita  or  adnata.  The  congenitally  weak  (prema- 
ture infants) — Managem.ent  of  congenitally  weak  infants:  incubators — 
Bath  and  clothing  of  the  congenitally  weak — Ultimate  fate  of  the  incu- 
bator infant — Feeding  of  the  congenitally  weak  and  premature  infants. 
Asphyxia  of  the  newborn  infant.  Asphyxia  subsequent  to  birth.  Atelec- 
tasis of  the  lungs.  Septic  infection  of  the  newborn  infant.  Diseases  of 
the  umbilicus — Omphalitis — Umbilical  fungus — Blennorrhcea  of  the  um- 
bilicus—Phlegmon of  the  umbilicus — Ulcer  of  the  umbilicus — Gangrene 
of  the  umbilicus — Erysipelas  of  the  umbilicus — Infection  of  the  umbilical 
vessels — Phlebitis  umbilicalis — Hemorrhage  from  the  umbilicus — Idio- 
pathic hemorrhage  from  the  umbilicus — Umbilical  hernise.  Peritonitis  of 
the  newborn.  Tetanus  of  the  newborn  infant.  Icterus  in  the  newborn 
infant.  Icterus  gravis  of  the  newborn.  The  occurrence  of  hemorrhage 
in  the  newborn.  Melsena  neonatorum.  Acute  fatty  degeneration  of  the 
newborn.  Winekel's  disease.  Sclerema.  Ophthalmia  neonatorum.  Caking 
of  the  breasts.  Mastitis.  Injuries  inflicted  during  birth.  Paralyses. 
Hasmatoma  of  the  sternomastoid.     Cephaloh^matoma 165-236 


SECTIO^^  IV. 

DISEASES  DUE  TO  DISTUEBANCES  OF  NUTEITION. 

Eachitis — Chondrodystrophia  foetalis — Osteogenesis  imperfecta — Infantile  scor- 
butus.    Marasmus  or  infantile  atrophy 237-264 

SECTIO^^  V. 

THE  SPECIFIC  INFECTIOUS  DISEASES. 

The  Exanthemata — Scarlet  fever.  Eotheln.  Measles.  Varicella.  Vaccina- 
tion— Other  specific  infectious  diseases.  Typhoid  fever.  Malarial  fever. 
Influenza.  Glandular  fever.  Meningitis — Cerebrospinal  meningitis — Acute 
lepto-meningitis.  Posterior  basic  meningitis.  Meningitis  serosa.  Mumps. 
Pertussis  convulsiva.  Diphtheria — Diphtheroid.  Scrofula.  Tuberculosis : 
fcetal  tuberculosis — Pulmonary  tuberculosis — Tuberculosis  of  the  peri- 
toneum; other  forms  of  tuberculosis  (larynx;  pleura;  pericardium) — 
Abdominal  tuberculosis  —  Tuberculous  meningitis — Tuberculosis  of  the 
brain.  Syphilis:  Acquired  syphilis — Late  hereditary  syphilis — Congenital 
or  hereditary  syphilis.  Acute  articular  rheumatism.  Eheumatoid  arthritis 
(Still's  disease).  Other  forms  of  so-called  rheumatism,  gonorrhoeal  form 
— Peliosis,  tonsillitis  with  joint  pains  and  endocarditis.  Erythema  nodo- 
sum, subcutaneous  rheumatic  nodules.     Muscular  rheumatism 265-467 


X  CONTENTS. 

SECTIOIS^  VI. 

DISEASES  OF  THE  MOUTH. 

PAGE. 

Physiological  facts — Physiology  of  the  nursing  act.  Landmarks  of  the  normal 
mouth.  Bacteria  of  the  mouth.  Normal  dentition — Abnormal  dentition. 
Pathology  of  dentition,  ulcerations  at  the  angles  of  the  mouth.  Bednar's 
aphthse,  sprue.  Aphthous  stomatitis,  toxic  stomatitis,  ulcerative  stoma- 
titis. Gonorrhceal  infections  of  the  mouth.  Pseudodiphtheritic  stomatitis. 
Noma.  Diseases  of  the  tongue.  Anomalies  of  size.  Eingworm — Des- 
quamation, tongue  swallowing — Tongue  tie — Malformations  of  the  uvula. 
Diseases  of  the  oesophagus.  Congenital  anomalies — Branchial  fistulas 
diverticulas — Stricture,  absence,  CEsophagitis — Caustic  oesophagitis.  Peri- 
oesophageal  abscess  468-492 

SECTIOE"  VII. 

DISEASES  OF  THE  STOMACH  AND  INTESTINES. 

Classification.  Anatomy  of  stomach,  capacity — Marking  out  the  stomach 
by  percussion.  Function  and  motility.  Acids  of  stomach — Stomach 
digestion — Intestinal  digestion.  Stools,  characteristics.  Acute  gastric 
dyspepsia.  Habitual  vomiting.  Cyclic  vomiting.  Other  forms  of  vom- 
iting. Colic — Tympanites.  Dilatation  of  the  stomach.  Ulcer  of  the 
stomach.  Spasm  and  congenital  stenosis  of  the  pylorus.  Acute  gastro- 
enteric infection.  Cholera  infantum.  Acute  and  subacute  enterocolitis. 
Dysentery  and  paradysentery.  Amoebic  dysentery.  Constipation  in  infants 
and  children.  Congenital  dilatation  of  the  colon.  Acute  intestinal  obstruc- 
tion. Appendicitis.  The  rectum — Prolapsus  ani.  Fissure  of  the  anus — 
Proctitis — Polypus  of  the  rectum.  Intestinal  parasites — Diseases  of  the 
liver.  Anatomical  considerations.  Tumors  and  conditions  simulating  en- 
largement. Jaundice — Congenital  stenosis  of  the  bile  ducts.  Cirrhosis 
of  the  liver — Fatty  degeneration  of  the  liver.  Syphilis  of  the  liver. 
Abscess  of  the  liver.  Acute  yellow  atrophy.  Tumors  of  the  liver.  Para- 
sites of  the  liver.  Biliary  calculi.  Diseases  of  the  peritoneum.  Ascites. 
Acute  peritonitis.  Gonococcal  peritonitis.  Pneumococcus  peritonitis. 
Simple  chronic  peritonitis 493-573 

SECTIOE"  VIII. 

DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Diseases  of  the  nose  and  nasopharynx — Acute  nasal  catarrh — Chronic  nasal 
catarrh — Diphtheritic  rhinitis — Foreign  bodies  in  the  nose — Epistaxis — 
Adenoid  growths — Acute  retropharyngeal  abscess.  Diseases  of  the  tonsils 
— Acute  follicular  amygdalitis — Herpes  of  the  tonsils — Ulceromembra- 
nous tonsillitis.  Diseases  of  the  larynx — Acute  catarrhal  laryrgitis — 
ffidema  glottidis — Syphilis  of  the  larynx — Tuberculosis  of  the  larynx — 
Growths  in  the  larynx — Foreign  bodies  in  the  larynx.  Diseases  of  the 
bronchi — Acute  simple  bronchitis — Fibrinous  or  plastic  bronchitis — Em- 
physema and  chronic  bronchitis — Bronchiectasis.  Diseases  of  the  lungs 
— General  considerations,  movements  of  the  chest,  normal  limits  of  the 


CONTENTS.  XI 


lung;  resiliency  of  the  chest  wall,  percussion,  auscultation,  types  of 
breathing,  forms  of  dyspnoea- — Pneumonia — Lobar  pneumonia — Broncho- 
pneumonia— Persistent  bronchopneumonia.  Diseases  of  the  pleura — 
Pleurisy — Dry  pleurisy — Pleurisy  with  effusion  and  empyema — Perforat- 
ing empyema — Hemorrhagic  pleurisy  and  empyema — Subphrenic  abscess 

574-673 

sections"  IX. 

DISEASES  OF  THE  CIECULATOKY  SYSTEM. 
Pericarditis — Adherent  pericardium.  Diseases  of  the  heart — Heart,  position, 
size,  apex  beat,  examination  of  the  heart — Congenital  heart  disease — Ste- 
nosis of  the  pulmonary  artery,  eonus  or  ostium — Open  ductus  arteriosus 
— Congenital  septum  defects — Maladie  de  Eoger — Acute  endocarditis — 
— Septic  endocarditis — Chronic  valvular  disease  of  the  heart — Cardiac 
murmurs — Accidental  cardiac  murmurs — Myocarditis — Hypertrophy  and 
dilatation  of  the  heart   674-710 


SECTIOIT  X. 

GENERAL  COXSTITUTIONAL  DISEASES. 
Diabetes  mellitus- — Diabetes  insipidus   711-714 

SECTIOlSr  XL 

DISEASES    OF    THE    LYMPH-NODES,    DUCTLESS    GLANDS, 
AND    THE    BLOOD. 

Diseases  of  the  lymph-nodes — Acute  adenitis — Chronic  lymphadenitis.  Dis- 
eases of  the  thyroid  gland — Enlargements  of  the  thyroid — Cretinism, 
endemic  and  sporadic.  Mongolian  Idiocy — Infantilism — Dwarfism — Nan- 
ism. Diseases  of  the  thymus:  landmarks,  weight — Percussion — X-ray — 
Hypertrophy  of  the  thymus,  status  lymphaticus,  thymus  death.  Diseases 
of  the  spleen:  anatomical — Examination  of  splenic  and  kidney  tumors. 
Diseases  of  the  blood — Leading  characteristics  in  infancy  and  childhood, 
the  red  blood-cells,  the  white  blood-cells,  the  hgemoglobin,  the  specific 
gravity — Anaemia — Simple  anaemia — Chlorosis — Pseudoleuksemic  anaemia 
of  von  Jaksch — Leukaemia — Acute  leukaemia — Chronic  leukaemia — Hodg- 
kin's  disease — Hemorrhagic  diathesis — Simple  purpura — Haemophilia — 
Purpura  hemorrhagica — Purpura  rheumatica — ^Henoch's  purpura — Per- 
nicious  ansemia.     Diseases   of   the   suprarenal   bodies — Addison's   disease 

715-754 

SECTIO^T  XII. 

DISEASES  OF  THE  BONES. 

General    considerations,    tuberculosis,    craniotabes,    syphilis — Acute    infectious 

osteomyelitis     7;j5-758 


xii  -  CONTENTS. 

SECTION  XIII. 

DISEASES  OF  THE  EAE. 

PAGE. 

Otitis  in  infancy  and  childliood.  Otitis  media  catarrhalis — Method  of  exami- 
nation of  the  ear  in  infants  and  children.  Mastoid  disease — General 
facts — Anatomy — Etiology — Symptoms — Diagnosis — Treatment    759-769 

SECTION  XIV. 

DISEASES  OF  THE  KIDNEYS  AND  UEOGENITAL  TEACT. 

General  anatomy — Floating  kidney — Cyclic  albuminuria — CEdema  and  hydra;- 
mia  without  kidney  lesion — Dysuria — Cellular  atresia  labia — Hsematuria 
— HEemoglobinuria- — Eenal  calculi — Acute  nephritis — Chronic  diffuse  ne- 
phritis— Growths  of  the  kidney — Cysts,  hydronephrosis,  sarcoma,  carci- 
noma— Tuberculosis,  peri-  and  para-nephritis,  enuresis,  nocturna  and 
diurna — Vulvovaginitis — Urethritis  in  male  children — Cystitis — Pyelitis — 
Pyelonephritis — Bacilluria    770-796 

SECTION  XV. 

DISEASES  OF  THE  NEEVOUS  SYSTEM. 

Convulsions  in  infancy  and  childhood — Eclampsia  infantum — Hysteria — Bad 
habits — Pica — Puddling — Thumb  sucking — Head  hanging — Masturbation 
— Tetany — Catalepsy— Myotonia — Congenital  stridor — Laryngismus  strid- 
ulus— Epilepsy — Pavor  nocturnus — Chorea — Forms  of  tic — Ehythmic 
movements  of  the  head,  with  nystagmus — Hydrocephalus — Amaurotic 
idiocy — Tumors  of  the  brain — Infantile  cerebral  palsy — Hemiplegic  infan- 
tile cerebral  palsy — Facial  palsy — Multiple  neuritis — Erb's  palsy — Hered- 
itary ataxia — Acute  encephalitis — Acute  poliomyelitis — Juvenile  form  of 
progressive  muscular  atrophy — Landouzy  type  of  facio-scapulo-humeral 
form  of  muscular  atroj)!!}^ — Pseudohypertrophic  muscular  paralysis — Idiocy 
— Deformities  of  skull  and  spinal  canal — Spina  bifida 797-883 

SECTION  XVI. 

DISEASES  OF  THE  SKIN. 

General  facts  —  Eczema  —  Erythema  multiforme  —  Furunculosis  —  Sudamina 
— Dermatitis  exfoliativa — Congenital   ichthyosis — Pemphigus  neonatorum 

884-895 


DISEASES  OF  INFANCY  AND  CHILDHOOD. 


SECTION  I. 

INFANCY  AND  CHILDHOOD. 

DEFINITION   OF   INFANCY   AND    CHILDHOOD. 

Infancy,  or  tlie  nursing  age,  is  the  period  of  life  during  which  the 
child  is  at  the  breast.     It  extends  from  birth  to  the  twelfth  month. 

Childhood  is  the  succeeding  period,  extending  to  puberty.  It  is 
customary  to  divide  childhood  into  two  periods- — the  first  extending 
from  the  end  of  the  first  to  the  sixth  or  seventh  year,  or  the  beginning 
of  the  second  dentition ;  the  second,  from  this  to  puberty. 

The  period  of  the  newborn  extends  to  the  third  month. 

MORBIDITY. 

The  Newborn  Infant. — The  diseases  of  the  newborn  are,  for  the 
most  part,  septic  in  nature,  and  attack  the  infant  within  a  short  time 
after  birth. 

Certain  conditions  favor  the  occurrence  of  the  diseases  common  at 
this  time  of  life.  The  skin,  not  fully  formed,  is  in  process  of 
desquamation,  and  bacteria  easily  gain  access  to  the  circulation.  The 
umbilicus  is  an  open  wound,  receptive  of  infection.  The  mucous 
membranes  of  the  intestine,  mouth,  eye,  and  ear  are  avenues  for  the 
entrance  of  bacteria.  There  is  a  tendency  for  minor  infections  to 
become  general  at  this  period.  The  artificially  fed  infant  is,  more- 
over, exposed  to  the  dangers  which  necessarily  accompany  the  intro- 
duction into  the  body  of  a  foreign  food  with  its  attendant  uncleanli- 
ness,  and  is  also  deprived  of  the  protective  bodies  (alexins)  contained 
in  the  mother's  milk.  With  new  surroundings,  in  a  new  atmosphere, 
with  new  appliances  for  maintaining  the  body-heat  (such  as  clothes), 
and  with  careless  handling,  the  newborn  infant  is  peculiarly  exposed 
to  disease. 

Childhood. — The  study  of  the  statistics  of  any  large  pediatric 
clinic  will  at  once  show  that  up  to  the  tenth  year  of  life  those  diseases 
which  affect  the  respiratory  apparatus  form  nearly  two-fifths  of  the 
cases.     ISText  in  order  of  frequency  are  the  diseases  of  the  digestive 

2  17 


18  INFANCY  AND  CEILBSOOD. 

tract ;  and,  lastly,  the  acute  infectious  diseases,  such  as  the  fevers  and 
exanthemata.  Of  53,040  cases  met  with  during  five  years  in  an 
ambulatory  clinic,  there  were  20,207  cases  of  diseases  of  the  respira- 
tory organs,  17,058  of  the  gastro-enteric  tract,  and  2409  of  the  acute 
infectious  diseases. 

If  the  morbidity  is  analyzed  still  further,  it  is  seen  that  in  the 
nursing  period  intestinal  disturbances  are  the  most  frequent.  The 
numerous  flora  of  bacteria  and  their  toxins  in  the  intestine  of  the 
infant  rather  predispose  to  infections  from  that  source.  These  bac- 
teria may  invade  the  mucous  membrane  of  the  intestine,  and  in 
certain  disturbances  of  the  functions  of  the  gut  obtain  access  to  the 
circulation.'  The  respiratory  diseases  become  more  frequent  in  the 
second  year,  and  reach  their  maximum  frequency  between  the  second 
and  third  years.  Constitutional  diseases,  such  as  rachitis,  appear  in 
the  second  half-year  of  life,  and  reach  their  greatest  frequency  during 
the  period  from  the  tenth  to  the  fifteenth  month.  On  the  other  hand, 
the  acute  infectious  diseases,  such  as  the  exanthemata,  are  more 
common  from  the  fifth  to  the  eighth  year.  Scarlet  fever,  with  its 
kidney  complications,  is  most  frequent  at  the  fourth  year  (Escherich), 
diminishing  at  the  ninth  year. 

The  period  extending  from  the  second  to  the  fourth  year  is  also 
notable  for  the  frequency  of  the  so-called  "  filth  infections  "  of  Peer. 
Children  infect  themselves  with  dirt  and  dust  at  play,  at  meals  or 
in  their  intercourse  with  one  another.  For  this  reason,  diphtheria  as 
well  as  pertussis  and  tuberculosis  (Escherich)  attain  their  maximum 
frequency  at  this  period. 

MORTALITY. 

In  large  cities  the  mortality  of  infants  is  naturally  greatest  among 
the  poor,  due  to  unhygienic  conditions.  With  the  well-to-do  artificial 
feeding  is  resorted  to  for  social  reasons,  but  among  the  poor  a  mother 
who  is  forced  to  make  her  livelihood  must  deny  the  breast  to  her 
child.  The  greatest  mortality  in  all  countries  occurs  in  artificially 
fed  infants.  In  England  two-fifths  of  the  whole  number  of  deaths 
occur  before  the  tenth  year  and  one-fourth  before  the  end  of  the 
first  year.  The  same  is  true  of  America.  The  modes  of  life  among 
the  poor  and  the  total  lack  of  isolation  in  contagious  disease  tend  to 
foster  this  great  mortality.  In  a  recent  brochure  Phelps  shows  that 
for  the  past  twenty-five  years,  the  mortality  among  infants  under  one 
year  of  age,  in  spite  of  the  great  advances  in  prophylaxis  and  infant- 
feeding,  has  remained  much  the  same  in  all  countries  the  world  over. 
He  places  the  rate  at  154  per  thousand  births,  whereas  Eross  found 
it  to  be  18fi  per  thousand.  In  answer  to  this  Holt  has  recently  shown 
that  the  greatest  mortality  among  infants  under  one  year  of  age  occurs 


SUDDEN  DEATH  AMONG  INFANTS  AND  CHILDBEN. 


19 


in  the  summer  months  from  gastro-intestinal  disorders  and  that 
during  the  past  hundred  years,  in  the  State  of  ISTew  York  at  least, 
there  has  been  a  gradual  improvement  in  the  death-rate,  though  the 
actual  number  of  deaths  is  certainly  greater  because  of  the  increase 
in  population.  The  following  tables  show  the  improvement  in  death- 
rate  during  the  past  four  years  in  the  State  of  ISTew  York. 


Total 
mortality. 


Mortality 

under 
5  years. 


Under 
1  year*. 


Total 
births. 


Annual 
number 
of  deaths 
under 
1  year 
to  1,000 
living 
births. 


Percentage    Percentage 


under 
1  year 
to  total 
deaths. 


of  deaths 
5  years 
to  total 
deaths. 


1904. 
1905.. 
1906. 
1907., 
1908. 


142,217 
137,435 
141,099 
147,130 
138,912 


14,177 
12,218 
12,176 
12,157 
11,380 


24,909 

25,827 
27,114 
28,011 
26,561 


165,014 
172,259 
183,012 
196,020 
203,159 


151.0 
150.0 
148.1 
142.9 
130.7 


17.5 
18.8 
19.2 
19.0 
19.1 


27.5 
27.7 
27.9 
27.3 
27.3 


This  encouraging  result  must  be  ascribed  to  the  improvement  of  the 
milk-supplies  in  large  cities,  the  education  of  the  poor,  the  introduc- 
tion of  serum-therapy  in  the  infectious  diseases,  and  a  livelier  interest 
in  the  prophylaxis  of  disease  with  consequent  absence  of  decimating 
epidemics. 


SUDDEN    DEATH    AMONG    INFANTS    AND    CHILDREN. 

Sudden  death,  that  is,  death  which  supervenes  unexpectedly  either 
in  apparent  health  or  in  the  course  of  disease,  is  very  frequent  in 
infancy  and  childhood.  It  is  not  quite  as  frequent  at  this  age  as  in 
adult  life.  It  is  well,  however,  to  recognize  that  this  form  is  of  daily 
occurrence,  lest  suspicion  as  to  the  cause  of  death,  in  any  case,  may 
unjustly  attach  to  the  physician  or  those  who  surround  th«  child. 
Sudden  death  may  be  traced  in  most  cases  to  anatomical  or  patho- 
logical conditions  either  in  the  circulatory  apparatus,  the  respiratory 
apparatus,  or  the  nervous  system.  Sometimes  the  cause  must  remain 
undetermined.  Finally,  it  may  supervene  during  or  after  surgical 
operations,  either  in  the  stage  of  anaesthesia  or  after  the  operation 
has  been  completed  and  the  patient  is  apparently  doing  well. 

Premature  Birth. — In  the  newborn,  if  premature,  death  may 
supervene  suddenly  when  the  infant  seems  to  be  doing  well.  In  such 
cases  there  is  simply  a  failure  of  the  circulatory,  as  well  as  respiratory 
and  nervous  functions.  Atelectasis  which  is  ascribed  to  most  of  these 
cases  as  a  cause  of  death  is  present  normally  in  these  premature 
infants.  The  lung  has  not  yet  expanded,  so  that  this  alone  cannot 
be  said  to  cause  death.  Many  of  these  cases  die  suddenly  in  con- 
vulsions.     Syphilitic  infants  though  doing   apparently  well    under 


20  INFANCY  AND  CHILDHOOD. 

treatment  may  be  found  dead  in  the  crib,  while  a  few  moments  before 
this  ending  seemed  improbable.  The  greatest  number  of  deaths  in  the 
newborn  is  certainly  found  among  the  illegitimate.  This  is  probably 
due  to  the  neglect  which  these  infants  suffer. 

Circulatory  Disturbances. — Hemorrhage,  either  cerebral  or  in 
haemophilia,  is  a  cause  of  sudden  death  in  the  newborn.  Rupture  of 
a  cerebral  artery  into  the  ventricle  of  the  brain  is  met  with  after 
difficult  labor.  Congenital  cardiac  disease  may  tend  to  sudden  death ; 
thus  Rauchfuss  describes  cases  in  nurslings  as  the  result  of  an  embolus 
from  the  ductus  Botalli  lodging  in  the  pulmonary  artery.  Aneurysm 
as  a  cause  of  death  is  rare  in  infancy  and  childhood,  but  there  have 
been  ruptures  of  such  aneurysms  without  previous  symptoms,  espe- 
cially in  connection  with  the  heart  in  which  aneurysm  has  resulted 
from  interstitial  myocarditis.  Rupture  of  an  aneurysm  of  the  large 
vessels,  such  as  the  aorta,  has  not  been  observed  during  childhood 
though  such  a  case  has  been  noted  later  in  life  by  Strlimpel  as  a  result 
of  the  rupture  of  a  congenital  aneurysm.  Carpenter  reports  the  case 
of  an  infant  twelve  months  of  age  dying  suddenly.  The  heart  was 
found  to  be  the  seat  of  extensive  fibroid  degeneration.  Any  form  of 
valvular  heart-disease  may  cause  sudden  death.  Erosion  of  the  larger 
bloodvessels  is  seen  as  a  sequence  of  retropharyngeal  abscess.  The 
rupture  of  the  artery  in  these  cases  leads  to  fatal  hemorrhage.  The 
myocarditic  death  seen  in  the  course  of  the  infectious  diseases,  such 
as  pneumonia,  typhoid  fever,  typhus  fever,  scarlet  fever,  and  diph- 
theria, will  receive  more  extended  consideration  later  on. 

Diseases  of  the  Respiratory  Tract. — Diseases  of  the  respiratory 
tract  are  a  very  important  factor.  That  ev^ry  case  of  sudden  death 
in  the  newborn  is  not  the  result  of  overlying  or  asphyxia  has  been 
shown  above.  Marantic  infants  and  children  who  are  suffering  from 
bronchopneumonia  of  a  chronic  type  are  prone  to  die  suddenly  while 
apparently  doing  well.  I  have  experienced  this  quite  often,  espe- 
cially in  hospital  practice.  A  cheesy  tuberculous  or  acutely  inflamed 
gland  may  erode  and  burst  into  the  trachea  and  thereby  cause  sudden 
death  by  suffocation.  A  retropharyngeal  abscess  may  cause  such  a 
death  by  bursting  spontaneously  above  the  larynx.  Marantic  children 
or  those  in  whom  the  pharyngeal  mucous  membrane  for  various 
reasons  has  lost  its  sensitiveness  may  suifocate  through  the  lodgment 
of  food  above  the  larynx  or  fluids  may  pass  from  the  stomach  into  the 
pharynx  and  thence  into  the  trachea.  This  has  occurred  during  sleep, 
the  infant  being  found  dead  in  its  crib  the  next  day.  The  rarer 
causes  are  congenital  atresia  of  the  trachea  or  pressure  on  the  trachea 
by  some  enlarged  lymph-node  or  a  congenital  tumor.  Such  anomalies 
may  cause  repeated  attacks  of  asphyxia  before  the  final  suifocativo 
attack.     In  a  majority  of  a  large  number  of  autopsies  on  infants  who 


SUDDEN  DEATH  AMONG  INFANTS  AND  CHILDBEN.  21 

suffered  sudden  death  Richter  found  a  tradieobronchitis  extending  to 
the  finer  bronchioles.  In  some  cases  the  larger  bronchi  may  become 
plugged  with  the  products  of  inflammation,  thus  causing  asphyxia. 
Pleuritic  exudates  of  large  volume  are  a  cause  of  sudden  death  in  the 
adult,  but  not  so  in  the  young  in  whom  the  right  ventricle  is  capable 
of  more  effective  work  and  the  resiliency  of  the  chest  wall  is  greater. 

Affections  of  the  Central  Nervous  System. — Affections  of  the 
central  nervous  system  may  lead  to  sudden  death.  Thus  an  undiag- 
nosed cerebral  abscess  following  an  otitis  may  cause  the  sudden  death 
of  the  individual  by  bursting  into  the  ventricle  of  the  brain  years 
after  the  otorrhoea  has  run  its  course.  Such  a  case  occurred  to 
Carpenter.  Embolism  and  cardiac  disease  may  result  in  cerebral 
hemorrhage  and  sudden  death  in  children  in  whom  no  heart  lesion 
was  previously  diagTiosed. 

Other  Causes. — Among  the  causes  not  yet  cited  are  the'  various 
intoxications  in  gastro-intestinal  disorders  or  in  the  forms  of  sepsis 
in  infancy.  Especial  interest,  attaches  to  hyperthermia  as  a  cause  of 
sudden  death  at  the  outset  of  the  infectious  diseases.  Liebermeister 
and  Thomas  first  called  attention  to  high  temperature  as  a  cause  of 
death.  Holt  has  observed  some  cases  and  I  have  seen  sudden  death 
with  very  high  temperature  follow  lumbar  puncture  in  cases  of  brain- 
tumor.  In  the  case  of  Thomas  the  child  was  of  lymphatic  constitu- 
tion. Feer  has  recently  called  attention  to  cases  of  eczema  which 
have  been  rapidly  healed  and  in  which  sudden  death  has  supervened 
in  the  patient  who  was  doing  well.  Most  of  these  children  are  also  of 
lymphatic  status.  I  have  heard  Henoch  express  a  fear  of  sudden 
death  after  the  too  energetic  and  rapid  cure  of  eczema  in  infants. 

Surgical  Causes. — The  surgical  causes  of  sudden  death  are  classi- 
fied by  Lubby  into  the  circulatory,  toxic,  infective,  mechanical,  those 
due  to  the  states  of  the  nervous  system,  and  finally  those  of  rare  and 
unusual  origin.  The  extended  consideration  of  all  these  is  not  feasible 
and  mention  may  be  made  only  of  what  seems  more  important.  Eatal 
hemorrhage,  in  abnormal  states  of  the  blood,  may  occur  from  the 
umbilicus,  the  intestine  and  as  the  result  of  the  simple  extraction  of 
a  tooth  or  a  circumcision.  Thrombosis  or  embolism  may  result  from 
the  injection  into  the  circulation  of  foreigTi  or  toxic  agents,  as  in  the 
treatment  of  nsevi.  Cold,  exposure,  or  undue  delay  in  operation  may 
be  a  potent  factor.  The  rapid  evacuation  of  the  pleura  in  a  case  of 
empyema,  or  the  subsequent  irrigation  of  the  pleural  cavity,  may 
cause  sudden  death  by  direct  insult  to  the  heart  or  by  the  change  of 
blood  pressure  acting  in  a  reflex  manner  on  the  vital  centers.  After 
operations  on  the  peritoneum,  as  in  appendicitis,  while  the  patient  is 
apparently  very  well  there  may  be  sudden  death  resulting  from  a 
thrombosis  of  the  pulmonary  artery  or  a  septic  myocarditis.     Acute 


22  INFANCY  AND  CHILDHOOD. 

oedema  of  various  kinds  may,  if  inflammatory  and  involving  the 
air  passages,  cause  sudden  death  by  direct  pressure. 

Mycotic  infections  of  all  varieties  are  a  cause  after  surgical  oper- 
ation. The  mechanical  obstruction  of  the  air  passages  by  foreign 
bodies  may  lead  to  a  sudden  exitus  and  needs  no  further  explanation. 
Operations  involving  the  larger  veins  by  admission  of  air  into  the 
circulation  are  a  rare  cause.  The  rapid  evacuation  of  the  cerebro- 
spinal fluid  may  be  a  cause  in  the  course  of  operations  on  the  nervous 
system.  It  should  be  mentioned  that  the  operation  of  lumbar  punc- 
ture has  been  followed  by  sudden  death  in  the  presence  of  a  tumor 
of  the  brain  or  in  infants  who  are  greatly  reduced  in  strength  and 
resistance  in  the  course  of  meningitis  or  hydrocephalus.  Sudden 
death  in  the  various  stages  of  anaesthesia  is  familiar  to  the  surgeon. 
Recently  its  frequent  occurrence  in  lymphatic  children  has  been  em- 
phasized by  Blake.  I  saw  one  case  of  death  from  cardiac  paralysis 
after  an  anaesthesia  in  an  appendical  operation,  the  cardiac  symptoms 
supervening  within  a  few  hours  after  the  operation.  The  appendix 
had  been  the  seat  of  a  mild  catarrhal  process,  but  there  was  no 
peritonitis.  The  heart-block  in  this  case  was  characteristic;  at  the 
wrist  the  pulse  could  scarcely  be  felt,  while  the  action  of  the  heart  was 
disordered  and  rapid,  beating  over  two  hundred  per  minute  with  no 
effective  filling  of  the  arteries. 

Lymphatism. — Finally  we  may  mention  the  cases  of  sudden  death 
in  infants  and  children  which  are  now  exceedingly  numerous  in  the 
literature.  They  occur  in  infants  and  children  who  are  the  subjects 
of  so-called  lymphatism.  There  may  be  symptoms  of  laryngismus 
stridulus,  with  or  without  convulsions.  There  may  be  rachitis  with 
signs  of  so-called  latent  tetany  or  there  may  be  the  outspoken  signs 
of  tetany.  Here,  the  infant  or  child  may  have  been  previously  in 
apparent  health  when  a  laryngismic  attack,  provoked  by  some  exami- 
nation of  the  patient,  with  or  without  convulsions,  ends  life  to  the 
consternation  of  the  physician.  In  cases  of  tetany  death  may  sud- 
denly supervene  without  any  previous  symptoms  that  would  warn  of 
the  impending  danger.  Post-mortem  changes  have  been  found  which 
will  be  described  later  under  the  heading  of  lymphatism.  The  inter- 
pretation of  these  changes  will  be  more  fully  considered  under  their 
proper  caption. 

THE    NORMAL    INFANT    AND    CHILD. 

A  knowledge  of  the  facts  connected  with  the  growth  and  develop- 
ment of  the  normal  infant  and  child  is  essential  to  the  understanding 
of  diseased  conditions  in  these  subjects.  Normal  children  vary  within 
certain  limits,  as  to  their  body-weight,  temperature,  pulse,  respiration, 


THE  NORMAL  INFANT  AND  CHILD. 


23 


and  secretion  of  urine,  in  a  manner  similar  to  sick  infants  in  the 
presentation  of  symptoms.  One  child  may  weigh  more  or  less  than 
another   of  the   same   affe,    and   still  be   in   excellent   health.      The 


Fig.  1. 


DAYS 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

t- 
I 

2 
3,100 

75 

50 

T 

/ 

/ 

h> 

\ 

1 

/ 

/ 

/ 

/ 

/ 

/ 

1 

1 

/ 

25 

3,000 
75 
50 
25 

2,900 
75 
50 
25 

/ 

/ 

/ 

/ 

/ 

/ 

/ 

\ 

/ 

\ 

/ 

\ 

/ 

\ 

/ 

\ 

/ 

\ 

/ 

' 

\ 

1 

6 

\ 

/ 

\ 

/ 

\ 

/ 

\ 

/ 

\ 

/ 

/ 

/ 

1 

/ 

/ 

\ 

/ 

/ 

' 

/ 

/ 

f 

/ 

/ 

1 

/ 

/ 

/ 

\ 

/ 

\ 

/ 

J 

\ 

/ 

^ 

/ 

1 

Normal  curve  of  weight  during  tbe  first  ten  days  of  life.      (Budin.) 

physician  must  take  into  account  not  only  the  infant  itself,  but  con- 
ditions of  heredity  and  surroundings.  There  is  absolutely  no  unvary- 
ing picture  of  a  normal  child.  There  are  limits  of  variation,  and 
these  the  physician  should  endeavor  to  master. 


24 


INFANCY  AND  CHILDHOOD. 


Body-weight. — During  the  first  two  or  three  days  following  the 
birth  of  the  infant  there  is  a  loss  of  body-weight.  Usually  this  loss 
amounts  to  from  150  to  200  grammes,  or  5  to  6^  ounces  (Fig.  1). 
It  is  even  greater  in  some  infants.  The  passage  of  meconium  and 
urine,  the  exhalations  from  the  skin  and  lungs,  and  the  small  amount 
of  nourishment  taken  by  the  infant  account  for  this  loss.  As  nursing 
begins  the  weight  increases  until  the  seventh  day,  when  the  infant, 
under  normal  conditions,  will  have  regained  its  original  weight.     On 

Fig.  2. 


MONTHS 

2          3          4          5          6           7          S          9          10          11          12                             1 

DAYS 

1            ' 

1          WEEKS 

1       1 

_     123456759 

0  tl  12  15  W        I 

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Author's  chart  showing  the  average  weight  of  breast-fed  infants  from  birth  to  the  end 

of  the  fifty-second  weel£. 

the  tenth  day  the  infant  weighs  100  grammes,  or  3.|  ounces,  more 
than  at  birth. 

In  some  cases,  if  the  infant  is  placed  immediately  after  birth  on 
a  breast  which  secretes  milk  abundantly,  it  will  not  lose  any,  or  but 
little,  weight. 

In  an  investigation  by  Gundling  it  was  noted  that  many  infants 


THE  NOBMAL  INFANT  AND  CHILD.  25 

ceased  to  lose  in  weight  after  the  second  day,  and  an  almost  equal 
number  on  the  third  day.  Boys  lost  more  than  girls,  and  the  infants 
of  multiparse  less  than  those  of  primiparse.  The  average  entire  loss, 
however,  was  about  241  grammes.  Most  infants  regain  their  original 
weight  on  the  ninth  day.  The  average  infant,  according  to  Camerer, 
at  birth  weighs  3450  grammes ;  and  according  to  Budin  there  is  a 
physiological  loss  of  the  amount  indicated  above,  which  is  rapidly 
regained  from  the  seventh  day  on,  when  the  weight  rises  in  a  physio- 
logical curve  throughout  the  remainder  of  infancy. 

From  the  second  week  to  the  fourth  month  an  infant  gains  1 
ounce  (30  grammes)  daily,  or  1^  to  2  pounds  a  month,  the  latter  in 
the  first  two  months ;  from  the  fourth  to  the  sixth  month  it  will  gain 
2  to  f  of  an  ounce  daily  (lY  to  20  grammes),  or  about  a  pound  a 
month.  From  the  sixth  to  the  twelfth  month  the  infant  gains  ^ 
ounce  daily  (15  grammes),  or  a  pound  a  month. 

An  infant  at  the  sixth  month  should  weigh  twice  its  initial  weight ; 
and  at  the  end  of  the  twelfth  month  a  normal  infant  should  weigh 
20  to  21  pounds,  or  9000  to  9800  grammes  (Fig.  2). 

Within  physiological  limits  the  weight  given  above  will  vary, 
and  there  are  normal  infants  who  may  weigh  a  pound  less  or  a  pound 
more  than  the  figures  given.  This  is  accounted  for  by  variation  in 
the  size  of  the  skeleton,  so  that  we  cannot  fix  an  absolute  weight  of 
20  or  21  pounds  as  the  normal  weight  of  an  infant  at  the  end  of 
twelve  months,  but  only  as  an  average  weight. 

Increase  of  weight  differs  also  in  artificially  fed  (bottle-fed),  as 
compared  to  breast-fed,  infants.  The  quantity  of  milk  necessary  to 
maintain  nutrition  is  greater  than  in  the  case  of  the  breast-fed  infant. 
There  is  always  the  danger  of  overfeeding  an  infant  on  the  bottle. 
The  increase  in  weight  is  not  so  regular  as  in  the  breast-fed  infant, 
as  is  shown  in  the  following  table  : 


Camerer  ! 


Weeks     1—2     2—4     4—8     8—12     12—16     16—20     20—24 
Increase    4  21         21  22  22  25  22 

Weeks  24—28     28-32     32—36     36—40     40—52 

Increase  13  16  16  9  12 

I   Months     1  23456789         10 

L  Weight  3810     4430     5090     5800     6550     7180    7650    8140    8600    8880 

^     ,.,      j  Months      123  4  5  6  7  8  9 

JvopjiK     ^  height  3735       5068       5285       5518       7688       7223       8680       9021 

In  the  table  above  and  that  on  p.  26  are  shown  in  grammes  not  only 
the  irregularity  in  the  daily  increase,  but  also  the  irregularity  in  the 
total  weight.  My  own  cases  were  examined  with  a  view  to  deter- 
mining what  an  arti-ficially  fed  baby  weighs  if  it  is  thriving.  The 
figures  correspond  closely  to  those  given  by  Camerer. 


26 


INFANCY  AND  CHILDHOOD. 


The  following  table  shows  in  grammes  the  daily  increase  of  weight 
of  the  breast-fed  and  the  bottle-fed  infant : 

Months.  ^^^^'^^^}  9^"?is''^'^  Koplik 

(breast).  (bottle).  (bottle). 

1 31  21  32.0 

2  .    .    . 26  22  17.4 

3  .    -    . 24  22  23  6 

4 21  25  18.0 

5 18  22  14.2 

6 ....  15  13  11.8 

7 15  16  15.6 

8 16  16  15.1 

9 9  9  — 

Length  of  Body. — At  birth  an  infant  measures  from  49  to  50 
cm.  (19§— 19f  in.)  in  length;  boys  on  the  average  have  a  greater 
length  than  girls.  During  the  first  year  the  increase  in  length  is  20 
cm.  (7|-  in.).  Thus,  at  the  end  of  the  fifteenth  year  the  length  of 
the  body  has  increased  100  cm.  (39^  in.). 

Head. — Herz,  in  a  number  of  measurements  of  the  head  of  the 
newborn  infant,  found  that  the 


Average  circumference  of  the  head  was 

Sagittal  diameter 

Large  transverse  diameter      .... 


39.2  cm.  (15.6  in.), 

11.1  cm.  (  4.4  in.). 

9.0  cm.  (  3.6  in.). 


The  latest  measurements  of  the  head  of  infants,  beginning  at  birth 
and  extending  to  the  twenty-fourth  month,  were  made  by  Hrdlicka 
and  Pisek,  under  the  guidance  of  Dr.  Chapin.  These  measure- 
ments are  applicable  to  American-bom  infants,  and  are  probably 
the  most  reliable  we  have.     (See  table  below.) 


Oircumference ' 

of  the  Head. 

Age. 

Male. 

Female. 

1st  day  to   end  of  1st  month < 

5th  to  6tli  month | 

11th  to  12th  month *    "   I 

22d  to  24th  month | 

35.1-38.3  cm. 
13.8-15.1  in. 

40.5-43.9  cm. 
16.0-17.3  in. 

44.7-45.3  cm. 
17.6-17.8  in. 

47.6-49.0  cm. 
18.7-19.3  in. 

33.4-37.1  cm. 
13.1-14.6  in. 

41.7-44.6  cm. 
16.4-17.6  in. 

43.7-46.3  cm. 
17.2-18.2  in. 

45.6  cm. 
18.0  in. 

The  newborn  infant  has  a  formation  of  the  caput  suc^edaneum 
and  in  some  cases  of  a  cephalohcematoma,  which  will  be  treated  of 
in  a  separate  section.     The  fontanelles,  however,  are  of  importance 

'  The  circumference  is  taken  just  above  the  glabella  in  front  and  the  external 
occipital  protuberance  behind. 


THE  NOBMAL  INFANT  AND  CHILD.  27 

and  may  be  spoken  of  in  this  connection.  They  are  caused  by  the 
apposition  of  the  cranial  bones — the  parietal,  frontal,  and  occipital 
^-which  at  first  are  circular,  and  at  the  points  of  non-contact  form 
triangular  spaces,  the  fontanelles.  These  spaces  are  at  first  closed  by 
membrane  only.  At  birth,  or  soon  thereafter,  the  posterior  fontanelle 
closes ;  the  anterior  fontanelle,  however,  remains  open.  The  time  of 
closure  of  the  anterior  fontanelle  is  of  the  utmost  clinical  importance. 
Kassowitz  and  Hochsinger  contend  that  the  anterior  fontanelle  grows 
smaller  from  birth  to  the  end  of  the  first  year,  and  closes  at  from  the 
twelfth  to  the  fourteenth  month.  Elsasser  and  Ehodes,  however,  con- 
tend that,  while  the  lateral  and  posterior  fontanelles  close  during  the 
first  months  of  infancy,  the  anterior  fontanelle  increases  in  its  longi- 
tudinal and  transverse  diameters  with  the  growth  of  the  cranium  up 
to  the  twelfth  month.  Most  writers,  however,  are  inclined  to  accept 
the  view  of  Kassowitz  and  Hochsinger.  If  the  closure  of  the  anterior 
fontanelle  is  delayed  until  the  fifteenth  month,  we  may  look  upon  it 
as  a  sign  of  rachitis. 

Respiratory  Functions. — Shape  of  the  Chest.^ — The  ribs  of  some 
infants  are  quite  apparent  to  the  eye,  while  those  of  others  are  con- 
cealed by  a  panniculus  of  fat.  The  normal  chest  in  the  child  has  not 
the  shape  it  assumes  later  in  life- — that  of  a  truncated  cone.  The 
later  portions  are  quite  straight  and  parallel.  The  chest  is  not 
flattened  anteroposteriorly  to  the  same  extent  as  in  the  adult.  In  the 
newborn  infant  the  transverse  diameter  of  the  thorax  is  twice  that  of 
the  anteroposterior  diameter ;  whereas  in  the  adult  it  is  three  times 
its  length.  In  infants  the  superior  border  of  the  manubrium  sterni 
is  on  a  level  with  the  midsection  of  the  first  dorsal  vertebra ;  in  the 
adult  it  is  lower  by  a  body  and  a  half  of  a  vertebra.  The  tendon 
of  the  diaphragm  is  horizontal  in  the  newborn  infant,  and  will  be 
found  to  be  on  a  level  with  the  disk  between  the  eighth  and  ninth 
dorsal  vertebra?.  A  rachitic  chest  may  be  pointed  at  the  sternum, 
forming  what  is  called  a  chicken-breast.  Some  rachitic  chests  show 
a  marked  flaring  of  the  lower  ribs,  with  a  lateral  incurvation  above 
this  flaring;  or  they  are  flattened  at  the  sides  and  deeper  at  the 
sternum.  The  sternum  may  be  the  top  of  a  truncated  cone,  a  varia- 
tion from  the  normal  state.  Infants  and  children  who  have  had 
several  attacks  of  bronchitis  and  who  have  emphysema  of  the  lungs 
show  a  marked  fulness  at  the  upper  part  of  the  chest,  underneath 
the  clavicles. 

Chest  Circumference. — The  following  measurements  of  chest  cir- 
cumference are  important  as  showing  the  development  of  American- 
born  infants  from  birth  to  the  twenty-fourth  month,  and  were  made 
by  Hrdlicka  and  Pisek : 


28 


INFANCY  AND  CHILDHOOD. 


Chest  Chxumference. 

Age. 

Male. 

Female. 

1st  day  to  end  of  1st  month < 

5th  to  6th  month i 

11th  to  12th  month | 

13th  to  14th  month | 

23d  to  24th  month | 

32.0-36.7  cm. 
12.6-14.4  in. 

39.9-43.3  cm. 
15.7-17.0  in. 

43.4-45.1  cm. 
17.1-17.8  in. 

42.1-47.7  cm. 
16.5-18.8  in. 

50.7-50.8  cm. 
19.9-20.0  in. 

30*0-35.9  cm. 
11.8-14.1  in. 

38.6-43.2  cm. 
15.2-17.0  in. 

42.8-48.3  cm. 
16.9-19.0  in. 

45.1-49.4  cm. 
17.8-19.0  in. 

47.1  cm. 
18.5  in. 

Normal  Number  of  Respirations. — The  normal  number  of  respira- 
tions in  infants  and  children  are  as  follows : 


Immediately  after  birth 44  per  minute. 

From  the  1st  to  the  2d  month 24-36         " 

2d      "       5th     "        20-32 

"         6th     "      10th  year 20-28 


The  character  of  the  respiratory  movements  in  infants  and  chil- 
dren is  quite  shallow  and  irregular,  especially  in  sleep,  as  compared 
to  the  adult.  Respiration  is  of  the  diaphragmatic  type  up  to  the 
tenth  year  in  the  female  child,  and  the  eleventh  year  in  the  male,  when 
it  takes  on  the  regular  type  of  respiration  seen  in  the  adult. 

Chemism  of  Respiration.- — Infants  nourished  upon  the  mother's 
breast  excrete  less  CO2  than  adults  (Rubner,  Heubner,  Bendix). 
Thus,  a  baby  weighing  5  kilos  (11  pounds)  exhales  13.5  COo  per 
square  metre  of  surface ;  whereas  the  adult  exhales  per  square  metre 
15.3  to  16.5  CO2  (Rubner).  On  the  other  hand,  the  breast-fed 
child  excretes  a  greater  amount  of  water  by  way  of  the  skin  and 
lungs  than  the  adult,  on  account  of  increased  respiratory  action, 
general  activity  of  the  infant,  and  its  warmer  apparel. 

The  bottle-fed  baby  excretes  a  greater  amount  of  CO2  and  water 
by  the  skin  and  lungs  than  the  breast-fed  baby.  This  is  explained 
by  the  fact  that  the  bottle-fed  infant  consumes  in  its  food  a  greater 
amount  of  nitrogen  than  the  breast-fed  infant. 

Circulation  and  Pulse. — -Circulation. — According  to  the  investiga- 
tions of  Vierordt,  the  circulation  in  the  newborn  infant  is  completed 
in  12  seconds;  in  the  child  of  three  years,  and  up  to  the  seventh 
year,  in  15  seconds;  in  the  child  of  fourteen  years,  in  18  seconds; 
and  in  the  adult,  in  22  seconds. 


TEE  NORMAL  INFANT  AND  CHILD. 


29 


Table  of  the  Avei'age  Height,  Weight,  Head  Circumference,  and  Chest 
3f€osu7'ements  of  American  Boys  and  Girls. 


(Collated 

from  thousands  of  children  in  various  States  by  Bowditch, 

Burk 

MacDonald 

,  and 

Hastings.) 

Years 
of  age. 

Sex. 

Hei 

ght. 

Weight. 

Head 
circum. 

Depth 
of  chest. 

Breadth 
of  chest. 

Chest  ex- 
pansion. 

In. 

Cm. 

Lbs. 

Kilos. 

In. 

Cm. 

In. 

Cm. 

In. 

Cm. 

In. 

Cm. 

fBovs. 

IGiris. 

41.7 

105.9 

41.6 

18.9 

20.1 

51.2 

4.9 

12.3 

7.1 

18.1 

1.3 

3.4 

5J4- 

41.3 

104  9 

40.7 

18.5 

19.7 

50.2 

4.8 

12.3 

7.0 

17.7 

1.4 

3.5 

6^. 

/Boys. 
1  Girls. 

43.9 

111.9 

45.2 

20.5 

20.2 

51.5 

5.0 

12.8 

7.2 

18.4 

1.6 

4.2 

43.3 

109.0 

43.4 

19.5 

19.8 

50.3 

4.9 

12.3 

7.0 

17.7 

1.5 

3.8 

'^y2- 

fBovs. 
t  Girls. 

46.0 

116.8 

49.5 

22.5 

20.4 

51.9 

5.1 

12.9 

7.4 

18.9 

1.8 

4.5 

4,5.7 

116.0 

47.7 

21.6 

20.0 

50.9 

4.9 

12.5 

7.2 

18.4 

1.8 

4.5 

SH. 

'  Boys. 

48.8 

123.9 

54.5 

24.4 

20.5 

52.2 

5.1 

12.8 

7.6 

19.4 

2.3 

6.9 

i  Girls. 

47.7 

121.1 

52.5 

23.8 

20.2 

51.2 

4.9 

12.5 

7.4 

18.9 

2.0 

5.0 

9}4- 

/Boys. 
1  Girls. 

50.0 

127.0 

59.6 

27.0 

20.6 

52.4 

5.2 

13.2 

7.8 

19.7 

2.5 

6.5 

49.7 

126.2 

57.4 

26.0 

20.4 

51.9 

5.1 

13.1 

7.0 

19.3 

2.2 

6.6 

1014. 

f  Bovs. 
1  Girls. 

51.9 

131.8 

65.4 

29.5 

20.6 

52.6 

5.2 

13.2 

8.0 

20.2 

2.7 

7.0 

51.7 

131.3 

62.9 

28.5 

20.5 

52.0 

5.1 

13.0 

7.8 

19.8 

2.4 

6.0 

\V-A. 

/Boys. 

53.6 

136.1 

70.7 

32.2 

20.8 

52.9 

5.4 

13.8 

8.2 

20.9 

2.9 

7.3 

iGirls. 

53.8 

136.6 

69.5 

31.5 

20  7 

52.5 

5.2 

13.1 

8.0 

20.3 

2.6 

6.6 

12J4  . 

/Boys. 

55.4 

140.7 

76.9 

34.9 

21.0 

53.3 

5.6 

14.1 

8.5 

21.5 

3.0 

7.8 

IGirls. 

56.1 

142.6 

78.7 

35.7 

20.9 

53.0 

5.4 

13.8 

8.4 

21.0 

2.4 

6.2 

XW^. 

/  Boys. 
1  Girls. 

57.5 

146.0 

84.8 

38.5 

21.1 

53.5 

5.6 

14.3 

8.7 

22.1 

3.2 

8.2 

58.5 

148.6 

88.7 

40.3 

21.0 

53.5 

5.5 

14.1 

8.7 

22.1 

2.6 

6.6 

U14- 

/Bovs. 

60.0 

152.3 

95.2 

43.2 

21.3 

54.1 

5.9 

15.0 

8.9 

22.7 

3.3 

8.4 

IGirls. 

60.4 

1.53.4 

98.3 

44.6 

21.3 

54.1 

5.7 

14.5 

9.0 

22.9 

2.7 

6.8 

/Bovs. 

62.9 

159.7 

107.4 

48.8 

21.4 

54.5 

6.3 

16.0 

9.3 

23.6 

3.3 

8.4 

■10>2- 

IGirls. 

61.6 

156.4 

106.7 

48.5 

21.5 

54.6 

6.0 

15.3 

9.5 

23.8 

2.6 

6.5 

Table  of  Weight,  Length,  Head  Circumference,  and  Girth  of  Chest 
from  Birth  to  the  End  of  the  Fourth  Year. 


Age. 


Birth  .  .   . 

6  months 
12  months 

2  years .   . 

3  years .  . 

4  years .   . 


Sex. 


/Bovs. 
IGirls. 
/Boys. 
IGirls. 
/Boys. 
IGirls. 
/Bovs. 
IGirls. 
/  Boys. 
IGirls. 
/Boys. 
iGirls. 


Length. 


In. 

19.7 
19.3 
25.4 
25.0 
29.5 
28.7 
33.8 
32.9 
37.0 
36.3 
39.3 
38.8 


Cm. 

50.0 
49.0 
64.8 
63.6 
73.8 
73.2 
84.5 
82.8 
92.6 
90.7 
98.2 
97.0 


Weight. 


Lbs.     Kilos. 

7.4 

7.1 
16.0 
15.5 
21.5 
21.0 
30.3 
29.2 
34.9 
33.1 
37.9 
36.3 


7.2 

7.0 

9.8 

9.5 

13.8 

13.3 

15.9 

15.0 

17.2 

16.5 


Head 
circum. 


Chest 
girth. 


In. 

Cm. 

In. 

Cm. 

13.8 

35.1 

12.6 

32.0 

13.1 

33.4 

11.8 

30.0 

16.0 

40.5 

15.7 

39.9 

16.4 

41.7 

15.2 

38.6 

17.8 

45.3 

17.8 

45.1 

18.2 

46.3 

19.0 

48.3 

19.3 

49.0 

20.0 

50.8 

18.0 

45.6 

18.0 

48.0 

19.3 

49,0 

20.1 

51.1 

19.0 

48.4 

19.8 

50.5 

19.7 

50.3 

20.7 

52.8 

19.5 

49.6 

20.5 

52.2 

Pulse. — Its  Rapidity. — The  following  is  the  rapidity  of  the  pulse 
at  the  various  ages  of  infancy  and  childhood  given  by  Bednar : 

Beats  per  minute. 

Foetus 108  to  160 

First  two  minutes  of  life 72  to    94 

Fourth  minute  of  life 140  to  208 

Eighth  day  to  second  month 96  to  130 

Second  month  to  twenty-first  month 96  to  120 

Second  to  fifth  year 92  to  108 

Fifth  to  eighth  year 84  to  100 

Eighth  to  twelfth  year 76  to    96 


The  pulse-respiration  ratio  in  infants  is  as  3  or  5  to  1.  The 
respiration  in  these  little  subjects  being  30  to  32  a  minute,  the  ratio 
of  the  respiration  to  pulse  will  be  as  1  to  4  in  infancy;  1  to  5  or  6 


30  INFANCY  AND  CHILDHOOD. 

in  tlie  second  year.  Turning,  crying,  coughing,  or  any  excitement 
will  increase  the  pulse-beat  15  to  30  a  minute.  During  sleep  the 
pulse  varies  from  15  to  20  beats  per  minute.  After  the  third  month 
the  pulse  is  more  rapid  in  girls  than  in  boys. 

Rhythm  of  the  Pulse.- — The  rhythm  of  the  pulse  has  been  the  sub- 
ject of  much  investigation  by  various  observers;  the  following  are  the 
main  peculiarities  of  the  normal  pulse : 

(a)  In  infants  and  children  the  pulse  is  normally  arrhythmic  or 
irregular,  both  in  regard  to  time  intervals  and  its  relation  to  what  is 
known  as  the  respiratory  curve  in  sphyginographic  tracing. 

(&)  Dicrotism  is  a  normal  characteristic  of  the  pulse  in  infancy 
and  childhood.  The  irregularity  of  the  pulse  in  some  infants  and 
children  is  not  very  marked;  in  others  this  irregularity  becomes 
more  apparent  under  the  influence  of  undue  excitement.  Dicrotism, 
although  very  evident  and  due  to  the  great  arterial  elasticity  in  normal 
children  (Landois),  is  never  as  marked  as  in  children  who  are  the 
subjects  of  cardiac  disease,  pertussis  (heart  strain),  or  acute  infection 
(typhoid  fever).  On  the  whole,  it  may  be  said  in  regard  to  the 
pulse,  that  it  is  more  subject  to  variability  as  a  result  of  slight 
influences  than  that  of  the  adult. 

Body-temperature. — The  temperature  of  the  newborn  infant  will 
vary  from  36.9°  to  38.4°  C.  (98.4°-101.1°  F.).  The  latter  is  excep- 
tional. According  to  the  studies  of  Lachs,  the  average  temperature 
of  the  newborn  infant  varies  from  37.5°  to  37.9°  C.  (99.5°-100.2° 
F.).  After  the  first  bath  the  body-temperature  falls  1.7°  to  2.5°  F, 
Two  hours  after  the  first  bath  the  temperature  begins  to  rise,  and 
reaches  its  initial  height  within  twenty-four  hours,  or  sometimes 
later.  Li  premature  or  weakly  infants  the  temperature  does  not 
reach  its  original  height  for  fully  three  days,  and  in  some  instances 
it  may  never  reach  the  original  height. 

The  body-temperature  of  infants  shows  slight  fluctuations  during 
the  day  which  are  quite  normal.  The  maximum  temperature  in 
most  cases  is  reached  at  midday  or  during  the  afternoon ;  the  mini- 
mum, during  the  morning  and  evening.  The  daily  fluctuations  vary 
from  0.1°  to  0.3°  F.  The  daily  fluctuations  of  temperature  are 
more  regular  and  uniform  in  the  breast-fed  infant  as  compared  to 
the  bottle-fed  infant  (Marfan).  During  sleep  the  temperature  may 
sink  from  0.3°  to  0.5°  F,  (Alix  and  Vierordt).  In  a  general  way  we 
may  say  that  in  infants  and  children  any  rectal  temperature  ranging 
from  99.3°  to  100°  F.  is  normal. 

Crying,  excitement,  or  exercise  will  raise  the  temperature  in 
infants  and  children  from  one-half  to  several  degrees.  I  have  seen  an 
instance  of  a  boy,  seven  years  of  age,  with  a  normal  temperature, 
observed  throughout  the  course  of  two  or  more  years,  of  100.5°  F.  at 


TEE  NOBMAL  INFANT  AND  CHILD.  31 

midday,  which  would  rise  1°  F.  in  the  rectum  after  five  minutes' 
exercise.     This  boy  was  otherwise  in  perfect  health. 

The  following  table  of  body-temperatures  (rectal)  is  the  result 
of  the  investigations  of  Lachs,  Vierordt,  and  Alix : 

Newborn  infant 37.n°  to  37.9°  C.  (99.5°-100.2°  R). 

5-16  months 37.4°  to  37.9°  C.    99.3°-100.2°  R). 

20  months-4  years 37.5°  to  37.9°  C.  (99.5°-100.2°  R). 

5-9  years 37.6°  to  37.8°  C.  (99.6°-100.1°  R). 

Heat  Calories.- — Children,  according  to  Vierordt,  produce  more 
heat  calories,  per  kilo  of  body-weight,  in  the  twenty-four  hours  than 
do  adults;  thus,  in  children  there  are  130,681  calories  per  kilo 
produced  as  compared  to  the  adult,  where  we  find  39,640  calories. 
If,  on  the  other  hand,  we  accept  the  investigations  of  Rubner,  in 
which  the  calories  are  calculated  per  square  metre  of  body-surface, 
the  infant  does  not  use  up  any  more  calories  than  the  adult:  1050 
to  1200  as  compared  with  1300.  The  infant,  for  its  size,  therefore 
gives  off  more  heat  from  the  body-surface,  and  is  therefore  more 
sensitive  to  loss  of  heat  than  the  adult. 

Urine. —  Physical  Characteristics. — The  urine  up  to  the  eighth  day 
of  life  is  dark  in  color,  contains  epithelial  cells,  leucocytes,  and  uric 
acid  crystals.  After  the  eighth  day  the  urine  is  a  limpid,  clear, 
colorless  fluid.  The  urine  of  artificially  fed  infants  is  somewhat 
darker  than  that  of  breast-fed  infants,  and  especially  is  this  so  in 
any  disturbance  of  the  functions  of  the  intestine.  If  there  is  j  aundice 
the  urine  may  contain  biliary  pigment. 

The  urine  has  a  resinous  odor,  as  in  the  adult.  The  specific 
gravity  during  the  first  three  days  of  life  ranges  from  1010  to  1012 ; 
after  the  tenth  day,  when  the  infant  has  partaken  of  liquid  food,  the 
specific  gravity  falls  to  1003  or  1004.  It  frequently  happens  that 
the  newborn  infant  does  not  pass  urine  on  the  first  or  even  the 
second  day  of  life.  This  is"  sometimes  misinterpreted  as  due  to 
some  obstruction,  either  in  the  ureters  or  external  genitals.  From  the 
second  to  the  tenth  day  the  infant  voids  urine  two  to  three  times  in 
the  course  of  the  twenty-four  hours.  Ruge  and  Robin  found  that  at 
the  third  month  the  infant  voids  urine  ten  to  eleven  times  in  the 
twenty-four  hours,  passing  400  to  500  grammes  in  that  time;  at  the 
fifth  month,  400  to  500  grammes  daily ;  from  the  second  to  the  third 
year,  500  to  600  grammes;  from  the  third  to  the  fifth  year,  750 
grammes;  and  from  the  seventh  to  the  tenth  year,  1200  grammes 
daily  (Parrot  and  Robin). 

The  following  table  gives  not  only  the  quantity  of  urine  passed 
during  early  infancy  and  childhood,  but  shows  the  difference  in 
amounts  passed  by  the  breast-fed   and  the   artificially  fed   infant. 


32  INFANCY  AND  CHILDHOOD. 

It  will  be  seen  that,  owing  to  the  larger  gross  quantity  of  fluids 
taken  into  the  body  by  the  artificially  fed  infant,  the  amount  of 
urine  passed  is  greater  than  that  of  the  breast-fed  infant.  The 
amount  of  urine  is  also  dependent  on  the  composition  of  the  food. 
Camerer  has  shown  that,  as  a  rule,  every  100  grammes  of  liquid  food 
will  yield  68  grammes  of  urine. 

Daily  Quantity  of  Urine  (Reusing), 

Breast.  Bottle.       Specific  gravity. 

1st  day 8.4  35.8  1010 


2d 

3d 

4th 

5th 

7th 

8th 


26.8  71.0  1010 

40.9  135.8  1010 
60.8  187.0  1010 

liy.l  283.0  1005 

157.0  325.0  1005 

208.0  406.0  1005 


30th-150th  day ^^^lEreast  1012 

150th-325th" 425/^^^^'^  ^^^^ 

2d       year 675  1012 

3d-5th  " 600-1200  1010-1012 

6th         " 1295  1012 

10th       " 1866  1010 

The  infant  passes  five  or  six  times  as  much  urine  per  kilo  of 
body-weight  as  the  adult;  the  child,  three  or  four  times  as  much. 

Urea.^ — Urea  is  excreted  in  greater  quantities  by  the  artificially 
fed  infant  and  the  infant  fed  by  a  wet-nurse  than  by  infants  fed  at 
the  mother's  breast.  Reusing  found  that  in  the  infant  at  the  mother's 
breast  the  amount  of  urea  increases  from  the  first  to  the  third  day, 
when  it  is  highest.  The  reason  of  the  diminished  excretion  of  urea 
at  this  period  lies  in  the  fact  that  there  is  an  insufiiciency  of  food 

Daily  Amount  of  Urea. 

Breast-fed.  Bottle-fed. 

1st  dav 0.06  0.33 

2d     "' • 0.26  0.40 

3d     "  0.52  0.67 

4th  "  0.50  0.55 

5th  "  0.78  0.65 

6th  "  0.79  0.61 

7th  "  0.81  0.88 

30th-150th  day 0.94 

2d       year       9.87 

.3d-5th  "      13.9 

10th       "      20.4 

during  the  first  days  of  life.  The  tissues  of  the  body  are  burnt  up 
in  the  processes  of  metabolism,  hence  there  is  a  diminution  of  weight. 
Inasmuch  as  the  body  is  rich  in  fat,  this  is  burnt  first  and  nitrogen  is 
saved.  As  a  result,  the  nitrogen  excretion  in  the  first  days  is  less 
than  it  is  later,  when  sufficient  food  makes  up  for  the  loss  of  body- 


TRE  NORMAL  INFANT  AND  CHILD.  33 

weight.  Added  to  this  fact  of  insufficiency  of  food,  there  is  a  paucity 
of  fluid  nourishment  during  the  first  days,  causing  a  retention  in  the 
body  of  the  end-products  of  metabolic  processes.  After  the  first  few 
days  in  the  newborn  infant,  as  in  all  cases  of  starvation,  there  is  an 
increase  of  nitrogen  excreted  until  by  means  of  increased  food  metab- 
olism attains  its  equilibrium  and  urea  is  excreted  in  normal  quantities. 

Albumin. — Albumin  is  found  in  the  urine,  according  to  Flens- 
burg,  in  40  per  cent,  of  newborn  infants.  He  attributes  its  pres- 
ence to  the  existence  of  uric  acid  infarction  in  the  kidney  at  this 
time.  Other  authors  contend  that  albumin  is  not  present  normally 
in  the  urine  of  infants,  but  if  the  mother  has  during  labor  suffered 
from  eclampsia,  the  urine  of  the  newborn  infant  may  contain  albumin 
and  casts.  Czerny  regards  the  whole  question  of  albuminuria  in 
the  newborn  as  suh  judice,  inasmuch  as  in  the  cases  investigated, 
including  those  of  Flensburg,  no  mention  has  been  made  of  or  con- 
sideration given  to  disturbances  of  the  functions  of  the  intestine  or 
other  abnormal  conditions  which  might  have  been  present  at  that  time, 
and  he  is  inclined  to  believe  that  if  such  consideration  were  given, 
it  would  be  found  that  the  appearance  of  albumin  in  the  urine  of 
infants  is  in  some  way  connected  with  the  disturbances  of  the  func- 
tions of  the  intestine. 

Indican. — Indican  is  not  present  in  the  urine  of  the  healthy  breast- 
fed infant;  whereas  it  is  found  in  traces  in  the  urine  of  artificially 
fed  infants,  even  in  the  absence  of  any  disease.  It  is  especially  con- 
stant in  the  urine  of  infants  suffering  with  gastro-enteritis,  and  may 
be  present  in  the  urine  of  infants  suffering  from  a  number  of  mal- 
adies, especially  forms  of  suppuration.  It  is  present  in  the  urine  of 
infants  suffering  from  tuberculosis,  but  is  not  pathognomonic  of  that 
affection  (Zamfiresco). 

Acetone. — Acetone  is  present  in  small  quantities  in  the  normal 
urine  of  infants  and  children,  and  is  found  also  increased  in  quan- 
tity in  the  case  of  fevers,  such  as  the  exanthemata,  or  pneumonia. 
The  amount  of  acetone  increases  in  proportion  to  the  height  of  the 
fever.  It  disappears  or  diminishes  to  the  normal  quantity  with  the 
disappearance  of  the  fever.  It  is  enormously  increased  in  the  urine 
of  children  during  a  seizure  of  eclampsia.  It  is  not,  however,  the 
cause  of  the  eclamptic  seizure,  as  has  been  supposed.  The  cause  of 
acetonuria  is  not  clear.  It  is  due  neither  to  the  hindrance  of  respi- 
ration nor  to  fermentation  in  the  stomach  or  intestine ;  but  is  prob- 
ably due  to  splitting  up  of  the  nitrogenous  substances  of  the  body, 
inasmuch  as  it  is  increased  by  a  nitrogenous  diet,  and  may  be  caused 
to  disappear  by  an  exclusively  carbohydrate  diet  (Hammarsten). 

Diacetic  Acid. — Diacetic  acid  is  not  a  physiological  constituent  of 
the  urine,  but  occurs  chiefly  under  the  same  abnormal  conditions  as 

3 


34  INFANCY  AND  CHILDHOOD. 

acetone.  There  are  cases  in  which  acetone  but  no  diacetic  acid  ap- 
pears in  the  urine.  Diacetic  acid  is  often  found  in  the  urine  of 
children  suffering  from  fever,  such  as  the  exanthemata.  Inasmuch 
as  diacetic  acid  is  readily  decomposed  into  acetone,  it  is  probably 
an  intermediate  product  in  the  oxidation  of  ^-oxybutyric  acid  in  the 
organism.  Acetone,  diacetic  acid,  and  ^S-oxybutyric  acid  stand  in 
close  relationship  to  one  another. 

Urobilin. — Urobilin  is  absent  from  the  urine  of  the  breast-fed 
infant,  but  is  found  in  traces  in  the  urine  of  artificially  fed  infants 
(Giarre  and  Czerny). 

Dextrose.- — Dextrose  is  found  in  traces  in  the  urine  of  infants,  as 
it  is  in  that  of  adults.  Dextrose  is  not  found  in  the  urine  of  healthy 
infants,  and  only  appears  in  the  urine  of  infants  suffering  from 
gastro-intestinal  disturbances  who  at  the  same  time  may  be  taking 
food  rich  in  glucose  or  maltose  (Koplik). 

Casts. — Hyaline  and  epithelial  casts  may  be  found  in  small  num- 
bers in  the  urine  of  the  newborn  infant. 

Uric  Acid  Infarction. — Virchow  has  described  these  infarctions  in 
the  kidneys  of  newborn  infants.  They  consist  of  red  or  brownish- 
red  structures,  which  on  section  of  the  kidney  are  seen  to  be  depos- 
ited in  the  pyramids  of  the  organ,  stretching  from  the  papilla  of  the 
pyramid  halfway,  rarely  extending  to  the  border  of  the  medullary 
portion  of  the  organ.  They  exist  in  the  kidneys  of  the  newborn 
infant,  reach  the  height  of  formation  on  the  second,  and  are  not 
found  after  the  sixth  day.  In  the  newborn  infant  there  is  a  hyper- 
leucocytosis,  which  is  more  pronounced  in  those  cases  in  which  the 
cord  has  been  tied  late. 

The  quantity  of  uric  acid  in  the  urine  of  the  newborn  is  much 
greater  than  it  is  later.  In  the  tubules  of  the  kidney  there  is  an 
accumulation,  especially  in  the  tubuli  contorti,  of  a  hyaline  sub- 
stance which  is  the  result  of  cell  production.  In  this  hyaline  sub- 
stance are  deposited  crystals  of  uric  acid,  and  it  is  in  this  way  that 
the  infarctions  are  formed.  The  increased  uric  acid  is  in  some  way 
connected  with  the  hyperleucocytosis  above  mentioned ;  the  leucocytes 
are  disintegrated  and  uric  acid  thus  produced.  It  has  not  been  ex- 
plained, however,  why  there  is  an  increased  elimination  of  uric  acid 
with  resulting  infarctions  at  this  period  and  not  later  in  infancy. 

MENTAL   AND   PHYSICAL  DEVELOPMENT   OF    THE   INFANT. 

It  is  not  our  purpose  to  enter  into  every  detail  of  the  development 
of  the  senses  of  the  infant,  for  this  would  scarcely  be  called  for  in  this 
section.  On  the  other  hand,  there  are  certain  important  facts  which 
are  of  great  utility  to  the  physician  in  his  daily  clinical  work. 


MENTAL  AND  PHYSICAL  DEVELOPMENT  OF  INFANT.  3o 

Sight.— On  the  second  day  the  eyes  are  sensitive  to  light.  On  the 
twenty-first  the  eye  will  follow  a  light ;  and  at  the  beginning  of  the 
second  month  the  infant  will  notice  bright  colors.  At  the  third  month 
the  infant  will  recognize  a  familiar  face.  At  the  sixth  month  the 
infant  will  definitely  recognize  its  parents  apart  from  strangers. 

Hearing. — A  newborn  infant  is  deaf.  This  is  due,  it  is  snpposed,. 
to  the  blocking  up  of  the  Eustachian  tubes  with  mucus.  On  the 
fourth  day  there  are  evidences  of  hearing,  which  develop  from  this 
time  to  the  fifth  week,  when  loud  talking  or  noises  in  the  room  dis- 
turb the  infant.  At  the  sixth  month  the  infant  will  recogTiize  noises 
as  to  their  varying  tone. 

Taste. — The  sense  of  taste  is  not  fully  developed  until  the  sixth 
month.  From  the  fourth  day,  however,  an  infant  will  show  a  prefer- 
ence for  sweetened, "  as  compared  to  unsweetened,  dilutions  of  milk. 

Feelings  of  Pleasure. — An  infant  will  show  decided  pleasure  at 
the  sight  of  playthings  at  the  fifth  month,  but  can  hardly  be  said  to 
take  an  intelligent  interest  in  any  object  before  this  time. 

Power  to  Hold  the  Head  Upright. — The  newborn  infant  cannot 
hold  its  head  upright,  and  when  held  in  arms  the  head  will  sway 
from  side  to  side.  The  power  to  hold  the  head  upright  is  not  fully 
developed  until  the  fourth  or  fifth  month.  This  is  important  clinic- 
ally in  connection  with  certain  diseases,  such  as  amaurotic  idiocy, 
the  development  of  which  is  attended  with  a  loss  of  power  to  hold 
the  head  upright. 

Sitting. — The  infant  will  make  the  first  attempt  to  sit  up  at  the 
fourteenth  week ;  but  is  unable  to  sit  upright  without  assistance  until 
the  forty-second  week. 

Standing. — The  first  attempt  to  stand  without  support  is  made 
by  the  infant  at  the  tenth  month.  In  the  eleventh  month  the  infant 
may  not  only  stand,  but  even  stamp  its  foot.  Walking  and  standing- 
are  delayed  by  rachitis.  In  such  cases  the  infant  may  even  cry  if 
placed  on  its  feet,  on  account  of  the  pain  such  children  experience  in 
the  bones. 

Crawling  and  Walking. — The  infant  will  crawl  on  all  fours  in 
the  fifth  month.  Attempts  to  walk  begin  at  various  periods,  some 
infants  being  more  precocious  in  this  respect  than  others.  The  ear- 
liest attempts  to  walk  are  made  in  the  tenth  month.  At  the  four- 
teenth month  an  infant  will  walk  if  held  by  the  hand.  It  will  stand 
alongside  a  chair  in  the  fifteenth  month,  and  in  the  seventeenth 
month  a  child  will  walk  unsupported. 

Laughing. — An  infant  two  months  of  age  may  be  caused  to  laugh 
in  a  purely  reflex  fashion  by  gentle  titillation  at  the  corners  of  the 
mouth  or  on  the  chin.  An  intelligent  laugh,  however,  is  not  observed 
until  the  sixth  month. 


36  INFANCY  AND  CHILDHOOD. 

Kissing. — Kissing  involves  the  act  and  the  understanding  thereof, 
and  these  are  seen  combined  only  quite  early  in  childhood — the 
twenty-third  month. 

Memory. — True  memory  is  observed  first  in  the  tenth  month, 
when  the  infant  will  recognize  the  face  of  the  parent  after  a  short 
absence.  In  the  twenty-first  month  the  child  will  recognize  its 
parents  after  a  protracted  absence. 

Speech. — On  the  forty-third  day  the  infant  may  articulate  unin- 
telligible sounds.  At  the  fourteenth  month  it  will  be  able  to  say 
mamma  and  papa;  and  at  the  end  of  the  second  year  the  child 
attempts  the  formation  of  simple  sentences.  In  a  general  way,  it 
may  be  said  that  the  infant  will  show  signs  of  intelligence,  includ- 
ing sight,  hearing,  and  vocal  effort,  at  about  the  seventh  month,  and 
will  first  attempt  to  walk  at  the  tenth  month.  There  will  be,  of 
course,  a  wide  variation  in  different  infants  in  the  development  of 
the  senses ;  and  yet  we  will  always  recogTiize  as  pathological  the 
vacant  stare,  a  total  lack  of  utterance,  an  indifference  to  bright 
objects,  and  an  inability  to  stand  on  the  mother's  knee,  or  to  hold 
the  head  upright  at  the  seventh  month,  especially  if  other  abnor- 
malities, such  as  protruding  tongue,  are  present. 

METHODS    OF    EXAMINATION. 

History  Taking. — History  taking  is  an  art  which  may  well  be 
cultivated  by  the  physician,  for  in  a  detailed  history  are  often  found 
the  clues  to  an  obscure  case.  The  mother  or  nurse  of  the  infant  or 
child  is  the  best  observer  of  his  various  conditions,  and  the  physician 
should  not  lightly  reject  any  facts  given  to  him  by  an  anxious  mother. 

The  physician  should  not  approach  his  patient  with  any  pre- 
conceived notion  of  the  malady,  but  should  allow  the  disease  to  unfold 
itself  with  all  its  symptomatology;  he  should  also  have  a  definite 
routine  of  examination. 

Maternal  History. — The  details  of  maternal  history  are  exceed- 
ingly important,  especially  as  regards  miscarriages  or  difficulties  in 
labor.  The  difficulties  in  feeding  of  other  children;  the  details  of 
their  illnesses ;  the  presence  of  disease  in  any  collateral  branch  of  the 
family,  especially  any  nervous  disorders,  are  extremely  important. 
The  occurrence  of  a  similar  affection  in  other  children  of  the  same 
family  are  of  moment;  and  in  older  children  the  various  steps  of 
development  of  the  senses,  snch  as  sight,  hearing,  speech,  and  walk- 
ing, are,  in  nervous  affections,  of  pertinent  moment. 

In  an  infant  the  history  of  feeding  in  all  its  details  is  quite 
essential.  The  condition  of  the  bowels,  the  presence  or  absence  of 
vomiting,  and  in  older  children  the  history  of  dentition  are  of  col- 


METHODS  OF  EXAMINATION.  37 

lateral  interest.  A  previous  history  of  scarlet  fever,  measles  or 
diphtiieria  may  have  a  bearing  on  some  nephritic  affection  in  the 
patient,  and  pains  in  bones  and  joints,  as  well  as  muscular  pains  may 
explain  cardiac  murmurs.  The  mother  very  frequently  ventures  in- 
formation as  to  previous  operations  on  the  tonsils,  or  adenoids,  which 
may  be  of  use  as  a  guide  in  the  case. 

Parental  History. — The  details  of  the  parental  history  as  regards 
the  occurrence  of  tuberculosis,  rheumatism,  or  nervous  disorders  are 
of  importance.  The  tendency  of  other  children  in  the  family  to 
eclampsia  are  facts  of  value.  Having  elicited  the  details  of  the 
previous  history  the  physician  proceeds  to  obtain  the  minutiae  of  the 
present  illness.  His  routine  will  vary  essentially  as  to  whether  his 
patient  is  an  infant  or  child  of  advanced  age.  In  an  infant  the  feed- 
ing in  all  its  details,  and  its  successes  and  failures  are  of  great  im- 
portance. In  older  children  these  facts  though  essential  are  only  of 
collateral  interest. 

Onset  of  Illness. — This  is  of  import,  especially  as  to  whether  the 
onset  was  abrupt  or  acute  or  slow  and  insidious.  In  the  great  ma- 
jority of  cases  an  illness  in  infants  begins  with  fever,  chill,  cyano- 
sis, or  vomiting.  One  of  these  symptoms  may  be  present  to  the 
exclusion  of  the  others,  or  they  may  all  be  present,  or  the  illness 
may  be  ushered  in  with  a  convulsion.  The  condition  of  the  patient 
immediately  following  the  initial  symptom  constitutes  the  initial 
stage  of  the  illness.  Fever  or  unconsciousness  may  follow  a  chill  or 
convulsion,  or  the  patient  may  after  the  initial  symptom  develop  an 
eruption,  cough,  dyspnoea,  or  pain.  The  fever  may  subside  in  a 
few  hours,  and  the  temperature  return  to  normal,  with  a  subsequent 
rise,  preceded  by  a  chill,  cyanosis,  or  a  second  convulsion.  Older 
children  may  complain  of  pain,  as  adults  do.  In  the  case  of  an 
infant,  pain  in  the  chest  or  abdomen  may  be  indicated  by  an  increase 
in  the  number  of  respirations  or  a  sighing  or  moaning  with  each 
effort  at  respiration. 

The  vomiting  of  the  initial  stage  of  the  illness  may  not  be 
repeated,  or  it  may  recur  and  form  a  leading  feature.  The  nature 
of  the  vomited  matter  is  important.  It  may  have  an  acid  reaction 
or  odor,  or  may  consist  of  stomach  contents  mingled  with  biliary 
pigment.  It  may  be  streaked  with  blood.  In  serious  continued 
vomiting  it  may  assume  a  fecal  character.  Vomiting  may  occur 
with  the  ingestion  of  food  or  independently  of  it. 

The  amount  of  the  stomach  contents  and  especially  whether  this 
seems  to  those  in  charge  of  the  infant  more  or  less  than  the  amount 
taken  in  at  the  individual  nursing  should  be  noted. 

The  condition  of  the  bowels  is  of  importance.  The  movements 
may  be  numerous  but  of  normal  consistency  and  odor,  or  thev  mav 


38  INFANCY  AND  CHILDHOOD. 

be  diarrhoeal  and  liave  abnormal  features.  The  movements  may  be 
accompanied  by  tenesmus  or  prolapse  of  the  gut.  The  urine  of 
sick  infants  is  sometimes  not  passed  for  hours.  The  mother  will 
make  a  note  of  this  fact.  The  character  of  the  urine  is  next  to  be 
ascertained.  Its  passage  may  be  painful.  The  urine  may  stain  the 
diaper  yellow  (jaundice)  or  red  (lithiasis)  ;  it  may  contain  blood. 
Older  children  may  be  required  to  pass  the  urine.  The  quantity  is 
more  easily  estimated  in  older  children  than  in  infants.  With  the 
latter  we  should  be  cautious  in  drawing  conclusions  as  to  the  daily 
amount.  In  taking  a  history  as  above,  it  is  essential,  while  eliciting 
the  main  features  of  an  illness,  not  to  inquire  concerning  unimpor- 
tant details.  The  main  features  of  the  history  should  be  grasped 
and  completed  in  all  their  minutiae. 

Taking  the  Status  Praesens. — It  often  happens  that  the  infant  or 
child  is  asleep  during  the  first  portion  of  the  visit.  Under  that  con- 
dition the  respirations  and  pulse,  with  the  character  of  each,  can 
be  noted.  The  posture  during  sleep,  the  expression  of  the  face  and 
its  contour,  the  position  and  behavior  of  the  extremities  during  rest, 
are  of  the  greatest  import.  Respiration  during  rest  is  more  instruc- 
tive than  in  a  condition  of  unrest  and  wakefulness.  The  patient 
should  be  completely  undressed  for  examination.  This  is  done  as  a 
routine  procedure  even  in  cases  of  apparently  mild  illness.  Any 
eruption  on  the  skin  is  thus  forced  upon  the  attention  of  the 
physician. 

The  Skin. — The  condition  of  the  skin  is  noted  in  a  general  way, 
the  absence  or  presence  of  an  eruption,  general  form  of  the  body  and 
its  gross  nutrition,  the  shape  of  the  chest,  contour  of  the  abdomen  and 
extremities  as  to  their  conformity,  as  well  as  the  power  in  the 
muscles  and  their  contour.  The  weight  of  an  infant  is  of  essential 
importance,  especially  where  feeding  is  concerned. 

The  Head. — The  examination  of  the  head  should  begin  with  ob- 
servation of  its  size,  whether  normal  or  abnormally  small  or  large. 
The  general  shape  of  the  head  and  condition  of  the  bones  are  of 
importance  in  reference  to  the  presence  or  absence  of  rachitis  and 
areas  of  craniotabes.  The  manner  in  which  the  head  is  held  is  noted, 
as  bearing  on  the  presence  of  torticollis.  In  Pott's  disease  the  head 
is  held  rigidly  on  the  spine,  and  in  older  children  supported  with 
the  hands.  Some  infants,  for  instance,  amaurotic  idiots  and  those 
suffering  from  birth-paralyses  or  diptheritic  paralysis,  are  unable 
to  hold  the  head  upright.  In  forms  of  meningitis  the  head  is  re- 
tracted or  held  rigidly.  The  fontanelles  may  be  normal,  tense,  as  in 
meningitis  or  hemorrhage,  depressed,  or  abnormally  prominent ;  they 
may  be  closed  prematurely,  as  in  microcephalus,  or  open  beyond  the 
normal  period.     The  presence  of  tumors  underneath  the  scalp,  such 


METHODS  OF  EXAMINATION.  39 

as  cephalohsematoma,  should  be  noted.  The  condition  of  the  lymph- 
nodes  posterior  and  anterior  to  the  border  of  the  sternomastoid  muscle 
is  of  clinical  importance. 

The  Face. — The  expression  of  the  face  in  a  condition  of  rest,  and 
also  when  the  infant  or  child  cries,  may  enlighten  us  as  to  the  presence 
or  absence  of  paralyses.  These  may  be  localized,  involving  the 
muscles  of  one  organ,  such  as  the  eye,  or  the  v^hole  side  or  both  sides 
of  the  face  may  be  affected.  When  the  infant  is  asleep  the  mouth  is 
normally  closed  and  the  infant  breathes  through  the  nose,  the  tongue 
being  applied  to  the  roof  of  the  mouth.  In  so-called  mouth-breathing 
the  mouth  remains  open  during  sleep  and  the  tongue  is  observed  to 
lie  at  the  floor  of  the  buccal  cavity. 

Respiratory  Disorders. — In  abnormal  states,  as  adenoids,  the  breath- 
ing may  be  noisy;  the  cry  may  be  peculiar,  as  described  under 
retropharyngeal  abscess;  the  lips  may  be  cyanosed  or  the  seat  of 
rhagades  or  eruptions,  such  as  herpes ;  the  symmetry  of  the  face  may 
be  lost,  as  in  parotiditis  or  adenitis,  in  v^^hich  there  is  a  swelling  of  one 
or  both  sides  of  the  face. 

Cardiac  Disease. — Cardiac  disease  in  advanced  stages  gives  a  sad 
and  anxious  expression  to  the  countenance,  with  exophthalmus  or 
dilated  pupils. 

Facial  Paralysis. — Facial  paralysis,  either  partial  or  complete, 
causes  a  characteristic  facial  expression.  If  the  infant  cries,  or  the 
child  is  made  to  smile,  one  side  of  the  face  remains  immobile.  Even 
in  rest  the  angle  of  the  mouth  may  be  drawn  toward  the  unaffected 
side  of  the  face,  as  in  tuberculous  meningitis. 

Nuclear  Palsy. — ^In  nuclear  palsy  of  the  congenital  variety  de- 
scribed by  Moebius  and  Schap ringer  (pleuroplegia)  both  sides  of 
the  face  are  immobile,  and  the  face  has  a  mask-like  expression.  There 
are  no  folds  in  the  face  either  in  the  acts  of  laughing  or  crying. 

Basedow's  Disease.- — Basedow's  Disease  gives  a  peculiar  expres- 
sion to  the  face,  caused  by  the  prominent  eyeballs,  which  is  pathog- 
nomonic of  this  disease. 

Hydrocephalus.^ — Hydrocephalus  likewise  lends  a  peculiar  expres- 
sion to  the  face.  The  forehead  is  protuberant  and  overhanging.  The 
eyeballs  are  forced  downward,  and  the  sclera  are  seen.  The  face 
proper  is  small  as  compared  to  that  part  of  the  head  above  the  eyes. 
This  is  due  to  the  large  size  of  the  cranium. 

Rachitis. — Rachitis  at  times  causes  a  characteristic  facial  expres- 
sion which  is  likely  to  be  confounded  with  that  due  to  hydrocephalus. 
In  some  rachitic  infants  the  eyes  are  prominent  and  the  sclera  is 
quite  apparent.  The  orbital  plates  of  the  frontal  bone  being  thin, 
the  weight  of  the  brain  depresses  the  eyeball  to  a  very  slight  degree. 

Exhausting  Diseases. — Exhausting    diseases,    such    as    diarrhoea, 


40  INFANCY  AND  CHILDHOOD. 

cause  prominence  of  the  eyes,  giving  a  very  characteristic  exj^ression 
— the  so-called  hydrencephaloid  of  older  v^riters. 

Congenital  Syphilis. — Congenital  sy^Dhilis  in  some  cases  causes  a 
deformity  of  the  nose,  which  is  present  at  birth.  The  result  is  a 
peculiar  angular  deformity  of  the  normal  nasal  curve.  Looked  at 
sideways,  the  bony  septum  is  depressed ;  the  cartilaginous  septum  is 
still  intact.  An  acute  angle  between  the  two  results.  This  is  similar 
to  what  is  seen  in  destructive  forms  of  syphilis  later  in  life.  The 
facial  expression  is  characteristic  of  the  disease. 

Palpebral  Fissure. — The  angle  of  the  palpebral  fissure  is  altered 
in  conditions  such  as  Mongolian  idiocy.  In  this  affection  it  is  slightly 
oblique.  In  paralyses  of  the  ocular  muscles  the  palpebral  fissure 
itself  may  be  wider  in  one  eye  than  in  the  other.  In  such  cases,  one 
pupil  may  be  wider  than  the  other  (Horner's  symptom).  The  pres- 
ence or  absence  of  conjunctivitis,  keratitis,  nystagmus,  paralyses  of 
the  orbital  muscles,  the  condition  of  the  pupils,  are  all  points  of  im- 
portance in  determining  the  status  pr^esens.  In  diseases  of  the  brain 
or  its  coverings  an  ophthalmoscopic  examination  of  the  fundus  oculi 
should  be  made. 

Sight. — In  partial  or  total  blindness,  not  only  do  the  patients  fail 
to  notice  objects  placed  in  front  of  them,  but  there  is  in  addition  a 
vacant  facial  expression  or  stare.  If  the  blindness  is  total,  the  finger 
will  be  suffered  to  approach  the  eye  so  as  to  touch  the  cornea. 

Some  infants  have  a  tendency  to  hold  the  head  to  one  side.  This 
may  be  due  to  defective  vision  or  to  weakness  or  spasm  of  the  muscles 
of  the  neck.  In  cases  of  defective  vision  the  head  assumes  a  normal 
position  if  the  eyes  are  not  focused  on  any  object.  As  soon,  how- 
ever, as  an  effort  is  made  to  accommodate,  the  head  is  inclined  so  as 
to  bring  the  planes  of  vision  of  the  eyes  in  accord. 

Photophobia. — Photophobia  is  an  aversion  to  light,  and  is  due  to 
a  spasm  of  the  ocular  sphincter  in  diseases  of  the  conjunctiva  or 
cornea  (conjunctivitis,  corneal  ulcer). 

Nystagmus. — N^ystagmus  is  a  series  of  involuntary  nioveinents  of 
the  eyeball,  due  to  inefficiency  of  certain  muscles,  and  is  met  with  in 
conditions  of  corneal  opacity,  congenital  cataract,  albinism,  infantile 
amblyopia,  spasms,  nutation  or  head-nodding,  and  in  nervous  states, 
such  as  amaurotic  idiocy.  In  weakly  rachitic  infants  nystagmus  may 
be  exhibited  around  a  horizontal  or  vertical  axis  of  the  eyeball,  or  it 
may  show  itself  in  a  rotary  oscillation  of  the  globe.  It  is  made 
manifest  in  infants  by  causing  them  to  focus  some  bright  object, 
held  slightly  above  and  to  one  side  of  the  head. 

The  Chest. — ^ Position  of  the  Patient. — An  infant  should  be  so  held 
for  examination  that  the  examiner  and  the  patient  may  be  at  ease. 
Being  undressed,  with  the  thorax  exposed,  the  infant  is  first  held  by 


METHODS  OF  EXAMINATION. 


41 


the  attendant  with  the  head  looking  over  her  shoulder,  in  which 
position  the  arms  instinctively  clasp  her  neck  (Fig.  3).  The  patient 
so  placed  does  not  see  the  examiner.  The  spine  should  be  straight, 
so  that  in  percussing  the  sound  is  obtained  on  both  sides  under  the 
same  conditions.  To  examine  the  chest  anteriorly,  the  infant  is 
held  looking  forward,  the  anterior  aspect  of  the  thorax  facing  the 
examiner.  If  it  is  able  to  sit  up,  it  may  be  examined  in  the  sitting 
posture,  both  anteriorly  and  posteriorly. 

Fig.  3. 


Method  of  holding  the  infant  for  the  examination  of  the  posterior  portion  of  the  chest 

and  lungs. 


With  older  children  it  is  best  to  make  an  examination  with  the 
patient  sitting  upon  a  table  or  chair  in  a  position  convenient  to  the 
examiner.  If  confined  to  bed,  the  child  must  be  examined  in  bed. 
As  a  rule,  however,  it  is  preferable  to  have  the  patient  taken  out  of 
bed  into  the  light. 

Infants  and  children  sometimes  try  to  grasp  the  instruments  of  the 
examiner ;  gentle  suasion  will  reassure  them,  force  is  never  necessary. 

Instruments  Used. — Stethoscope. — A  stethoscope  is  absolutely  es- 


42 


INFANCY  AND  CEILDEOOD. 


sential  to  the  proper  examinatiou.  of  the  chest  of  an  infant  or  child. 
This  method  is  called  mediate  examination.  We  can  by  its  means 
assure  ourselves  that  the  whole  area  of  the  chest  has  been  carefully 
investigated.  Examination  by  the  ear — the  immediate  method — is 
uncertain.  A  small  area  of  bronchopneumonia  may  easily  escape 
detection  in  infants  and  children  of  tender  age,  in  whom  the  axillgs 
and  lateral  regions  of  the  chest  should  be  carefully  searched.  Direct 
application  of  the  ear  to  the  chest  is  resented  by  infants  and  children, 
and  is  not  a  convenient  procedure  for  the  physician.  With  the 
stethoscope  he  can  follow  the  movements  of  the  body  of  a  restless 
patient. 

The  best  form  of  stethoscope  to  employ  is  the  binaural.     The 
instrument  devised  by  the  author  (Fig.  4)  has  given  him  the  most 


Fig.  4. 


Author's  form  of  stethoscope.      (Archives  Ped._,  November,  1899.) 


uniform-  results.  A  larger  stethoscope,  such  as  that  employed  for 
examination  of  the  adult  chest,  does  not  differentiate  the  variety  of 
sounds  as  well  as  this  small  instrument,  and  may  cause  pain  to  a 
restless  infant,  inasmuch  as  the  chest-piece  must  be  held  too  rigidly 
and  is  likely  to  press  painfully  against  the  chest-wall. 

Tape-measure. — A  steel  tape-measure,  marked  off  into  inches  and 
centimetres,  is  convenient  for  detecting  inequalities  in  the  size  of  the 
sides  of  the  chest. 

Methods  of  Procedure.- — Inspection. — ^We  learn  by  inspection  the 
shape  of  the  chest  and  the  character  of  the  respiratory  movements : 
also,  the  aspect  of  the  cardiac  area,  the  pulsation  of  the  apex  of  the 
heart,  its  force  and  situation. 

Respiration  in  infants  and  children  up  to  the  age  of  ten  years  is 
of  the  abdominal  or  diaphragmatic  type.  The  rapidity  may  be 
counted  by  noting  the  movements  of  the  chest  or  by  watching  the 
rise  and  fall  of  the  epigastric  region  in  the  recumbent  patient. 

The  Cardiac  Area. — In  some  infants  and  children  the  cardiac 
area  may  be  quite  prominent  in  the  absence  of  any  cardiac  dis- 
ease. In  rachitic  infants  and  children  this  part  of  the  chest  wall 
may  conform  to  the  shape  of  the  heart.     There  remains  even  in  the 


METHODS  OF  EXAMINATION.  43 

later  childhood  of  rachitic  patients  a  very  slight  rotimditj  or  fulness 
of  the  precordial  region.  If  the  chest-wall  is  quite  thin,  the  precor- 
dial region  may  normally  present  a  wave  of  pulsation.  All  these 
signs  may  be  exaggerated  in  disease  of  the  heart.  The  apex-beat  is 
normally  distinguishable.  Its  force  and  area  may  be  increased  or 
diminished  in  disease.  The  apex-beat  may  be  displaced  upward 
and  outward,  or  inward  toward  the  median  line  (conditions  of  effu- 
sion in  pericardium  or  pleura). 

Palpation. — Palpation,  by  laying  the  palmar  surface  of  the  hands 
on  the  chest,  is  hardly  to  be  attempted  with  young  infants  and 
children.  In  these  subjects  the  chest  is  so  small  that  this  method 
cannot  mark  out  areas  of  fremitus  or  absence  of  the  same.  To 
deterniine  its  presence,  it  is  more  satisfactory  to  use  the  internal 
border  of  the  hand,  generally  the  right.  The  hand  is  held  horizon- 
tally, the  internal  border  pressing  firmly  against  the  chest-wall. 
Thus  the  slightest  variations  in  vibration  of  the  chest-wall  can  be 
detected.  We  begin  above  at  the  upper  border  of  the  chest  and 
pass  dovmward,  comparing  both  sides.  If  the  infant  or  child  cries, 
so  much  the  better.  If  we  wish  to  ascertain  the  presence  of  fremitus 
in  a  baby,  we  may  even  cause  it  to  cry.  An  excusable  procedure  is  to 
press  gently  the  cheeks  of  the  infant  with  the  thumb  and  index  finger 
in  a  teasing  manner;  the  infant  will  resent  this  by  crying.  Older 
children  may  be  asked  to  count  or  induced  to  talk.  In  infants  and 
children  fremitus  is  not  so  marked  or  useful  a  sign  as  in  the  adult. 
ISTormally,  it  diminishes  in  intensity  toward  the  base  of  the  lung.  In 
some  children  it  is  detected  in  the  lower  part  of  the  thorax  only  by 
careful  examination.  It  is  normally  well  marked  along  the  axillary 
line;  it  is  most  marked  along  the  mid-regions  of  the  chest  between 
the  scapulae  behind.  Anything  which  separates  the  lung  from  the 
chest-wall  will  diminish  or  extinguish  fremitus.  Solidification  of 
lung  tissue  will  cause  better  conduction  and  increase  it. 

Percussion.- — It  is  not  advantageous  to  use  a  pleximeter  in  ex- 
amining infants  and  children.  The  index  finger  of  the  left  hand 
is  laid  horizontally  on  the  chest  with  firm  pressure.  The  skin  or 
chest-wall  and  finger  are  thus  made  one  medium.  Percussion  is 
performed  by  making  a  hammer  of  the  middle  finger  of  the  right 
hand.  The  force  used  should  come  from  the  wrist;  the  forearm 
should  be  inmiobile.  The  stroke  is  expended  upon  the  middle 
phalanx  of  the  finger  on  the  chest-wall,  and  should  be  of  a  tapping 
character,  similar  to  that  used  in  striking  the  keys  of  a  typewriter ; 
there  should  not  be  a  pushing  motion.  The  force  should  not  be 
great.  A  force  equal  to  that  necessary  in  the  examination  of  the 
adult  chest  would  set  in  vibration  all  the  neighboring  chest  and 
abdominal  organs  and  cavities,  and  would  not  bring  out  the  delicate 


44  INFANCY  AND  CHILDHOOD. 

distinctions  of  sounds  necessary  to  diagnosis.  Moreover,  to  some 
rachitic  infants  and  young  children  a  forcible  stroke  is  distinctly 
painful. 

The  Abdomen. — The  abdomen  of  an  infant  or  child  is  best  ex- 
amined with  the  patient  lying  on  a  bed  or  a  table  covered  with  a  soft 
blanket.  The  mother's  or  nurse's  knees  are  not  so  satisfactory  a  sur- 
face for  this  purpose.     The  patient  should  be  completely  undressed. 

Inspection.^ — Inspection  should  include  the  examination  of  the  skin 
as  to  color,  presence  or  absence  of  an  eruption,  oedema,  and  of  the 
abdomen  as  abnormally  rotund  or  relaxed.  In  the  latter  condition 
we  may  sometimes  make  out  the  coils  of  intestine.  Peristalsis  should 
be  noted  especially  in  cases  of  persistent  vomiting,  obstruction  of  the 
intestine,  or  stenosis  of  the  pylorus.  In  diseases  which  exhaust  the 
strength  of  the  patient  we  distinguish  between  relaxed  and  retracted 
abdominal  walls.  A  retracted  abdominal  wall  may  be  tense  and 
incurvated — the  so-called  boat-shaped  abdomen ;  this  is  seen  in  menin- 
gitis. In  some  rare  forms  of  septic  peritonitis  the  abdomen  may  be 
retracted.  The  pain  of  a  colicky  attack  will  cause  the  abdominal 
walls  to  be  tense  although  not  retracted.  In  intussusception  the  coils 
of  intestine  or  even  the  intestinal  tumor  may  be  seen  on  the  surface. 
Ascites  distends  the  abdomen,  and  when  marked  the  rotundity  is 
characteristic,  and  the  skin  is  tense  and  shining. 

Peritonitis. — Peritonitis  causes  tympanitic  distention.  In  per- 
foration of  the  intestine  in  typhoid  fever  or  appendicitis  the  tympa- 
nites is  accompanied  at  an  early  stage,  as  in  the  adult,  by  disappear- 
ance of  the  liver  dulness.  This  sign  will  aid  us  more  if  the  liver 
dulness  and  flatness  have  been  determined  accurately  in  advance  of 
any  complications. 

Free  Fluid. — The  presence  of  free  fluid  of  an  inflammatory  na- 
ture may  be  determined  by  percussing  for  dulness  in  the  flanks  with 
a  change  to  tympanitic  resonance  in  the  same  situation  on  a  change 
of  position  as  in  the  adult. 

Tumors.- — Abdominal  tumors  give  an  uneven  contour  to  the  ab- 
domen. Such  tumors  are  met  in  diseases  of  the  spleen  or  kidney, 
enlargements  of  the  liver,  congenital  renal  cysts,  ovarian  tumors,  or 
hydatid  cysts. 

Palpation. — ^We  palpate  for  pain,  general  or  localized,  and  to 
determine  the  size  and  position  of  the  abdominal  organs;  for  tumor 
whether  of  or  behind  the  peritoneum,  tumors  of  the  liver,  kidney,  or 
spleen;  enlarged  glands  behind  the  peritoneum  in  the  neighboi'hood 
of  the  mesentery  of  the  small  intestine ;  polypi  in  the  lumen  of  the 
intestine ;  tumors  due  to  appendicitis  or  intussusception. 

In  palpating,  we  follow  a  certain  routine,  and  palpate  in  the 
region  of  the  spleen,  then  over  the  liver,  and  finally  in  the  right 
inguinal  region  (appendicitis). 


METHODS  OF  EXAMINATION.  45 

Ascites. — The  signs  are  the  same  as  in  the  adult. 

Tympanitis. — Tympanitis  gives  the  same  signs  as  in  the  adult. 
In  newly  born  infants  there  is  in  rare  cases  a  congenital  weakness 
of  the  walls  of  the  intestine.  Any  disturbance  of  the  intestinal  tract 
results  in  immense  distention,  which  may  be  distressing  to  the  patient, 
ifon-inflammatory  is  distinguished  from  inflammatory  distention 
(peritonitis)  by  the  absence  of  prostration  or  fever  and  the  absence 
of  free  fluid  in  the  abdominal  cavity.  There  is  another  form  of 
distention  which  precedes  death  in  severe  pneumonia  or  gastro- 
enteritis. Simple  tympanitic  distention  is  seen  in  rachitic  children, 
in  whom  the  lower  part  of  the  chest  is  narrowed  and  the  abdomen 
uniformly  protuberant ;  in  these  children  the  distention  is  apparently 
increased  by  the  forward  curvature  of  the  spine.  Percussion  gives 
a  uniformly  tympanitic  note  all  over  the  abdominal  area,  except 
where  fteces  change  the  note  into  a  dulness.  There  is  no  pain  or 
only  slight  general  tenderness. 

Pain. — Children  may  locate  the  pain  felt  in  pneumonia,  pleurisy, 
or  pericarditis  in  the  abdomen.  The  pain  in  these  cases  may  be 
referred  to  the  upper  part  of  the  abdomen.  The  patient  may  com- 
plain of  pain  radiating  to  the  right  inguinal  region,  and  thus  in  lobar 
pneumonia  of  the  lower  portion  of  the  right  lung  mislead  the  ex- 
aminer into  a  consideration  of  the  existence  of  appendicitis.  In 
diffuse  peritonitis  the  pain  is  general,  but  in  localized  disease  of  the 
vermiform  appendix  the  limitation  of  pain  can  be  made  out  even  in 
young  subjects.  If  we  suspect  appendicitis,  it  is  best  to  examine 
every  part  of  the  abdomen  for  pain  before  approaching  the  right 
inguinal  region. 

In  connection  with  pain  and  its  significance,  we  may  emphasize 
the  fact  that  if  the  abdomen  is  relaxed  (not  retracted),  showing  the 
grooves  due  to  the  muscular  parts  of  the  abdomen — the  bellies  of 
the  recti  muscles,  the  incurvation  of  the  abdomen  just  below  the 
border  of  the  ribs — we  may  assume  the  absence  of  tympanites.  In 
such  cases  peritonitis  is  rarely  present.  Pain,  which  has  no  definite 
localization  in  an  abdomen  relaxed  as  above  described,  may  be  con- 
sidered as  of  no  serious  import. 

The  condition  of  the  abdomen  in  intussusception  is  described  in 
the  chapter  treating  of  that  subject. 

Polypoid  tumors  in  the  lumen  of  the  ascending  or  descending 
colon  may  sometimes  be  distinctly  felt  in  the  relaxed  abdomen  to 
one  side  of  the  umbilicus. 

Floating  kidney  in  children  has  been  recently  described  by 
Comby.  The  methods  of  examination  in  forms  of  kidney  tumor  or 
displacements  of  this  organ  are  described  in  the  chapter  devoted 
to  those  subjects. 


46  INFANCY  AND  CHILDHOOD. 

Rectal  Exploration,- — This  is  always  carried  out  in  the  recumbent 
position.  Bv  rectal  examination  we  may  establish  the  presence  of 
an  abscess  in  the  right  inguinal  region  or  of  great  swelling  of  the 
appendix  in  cases  in  which  it  is  bound  down  by  adhesions  below 
the  brim  of  the  pelvis  or  of  ischiorectal  abscess.  Eectal  exploration 
is  resorted  to  in  all  eases  in  which  we  are  led  to  suspect  the  presence 
of  an  intussusception.  In  tuberculous  peritonitis  also,  enlarged 
lymph-nodes  may  be  felt  through  the  walls  of  the  rectum.  Kidney 
and  ovarian  tumors  can  in  some  cases  be  felt  through  the  rectum. 

It  is  not  necessary  to  cause  pain  in  the  above  procedure.     On 
the  contrary,  rude  examination  only  obscures  the  case.     We  should 
seek  every  opportunity  to  become  familiar  with  the  normal  condi 
tions  externally  and  per  rectum,  especially  in  the  vicinity  of  the  right 
inguinal  region  in  order  to  be  able  to  diagnose  abnormal  states. 

The  Joints. — Affections  of  the  joints  are  among  the  most  frequent 
diseases  of  infancy  and  childhood.  The  method  of  examination  of  the 
joints  should  be  familiar  to  every  physician.  If  a  mother  states  that 
her  baby  cries  when  it  is  bathed  or  diapered,  we  should  examine  the 
joints.  In  the  newborn  infant  especially  this  holds  true.  If  there  is 
any  limitation  of  motion,  or  should  the  extremities  be  limp,  the  joints 
should  be  inspected.  In  older  children  a  sudden  limp  or  intermittent 
obscure  pain  in  a  joint  should  receive  attention  at  once. 

Position.^ — To  examine  the  joints,  the  patient  should  be  completely 
undressed,  and  placed  on  a  table.  The  spontaneous  movements  of 
the  limbs  are  first  observed  before  any  manipulation  of  them  is 
attempted.  We  may  thus  observe  that  one  limb  is  favored  by  the 
infant,  limitation  of  motion  may  exist,  or  there  may  be  a  marked 
swelling  of  one  joint.  The  shoulder,  elbow,  knee,  ankle,  and  other 
joints  are  systematically  examined.  This  can  be  done  in  quite  a 
short  time  if  we  make  it  a  routine  of  every  physical  examination. 
In  examining  a  joint  we  should  not  forget  that  when  inflamed,  it  is 
very  painful  if  not  gently  handled,  and  that  any  rude  procedure, 
in  addition  to  causing  pain,  may  injure  the  joint. 

The  joint  is  inspected  as  to  whether  it  is  swollen,  or  has  its  normal 
form,  or  shows  too  plainly  the  prominences  of  the  bones  entering  into 
its  formation.  Palpation  will  tell  whether  the  temperature  of  the 
surrounding  tissues  is  raised,  whether  there  is  fluid  in  the  joint  or 
whether  the  tissues  about  it  are  infiltrated.  We  also  examine  by  mild 
pressure  with  the  fingers  the  region  of  the  junction  of  the  epiphysis 
and  diaphysis  for  tenderness. 

Motility.- — Motility  is  tested  by  flexing,  extending,  rotating,  ab- 
ducting, and  adducting.  During  such  an  examination  we  also  note 
muscular  spasm. 

Joint-crepitus. — Joint-crepitus   is    a    peculiar   crackling,    rubbing 


METHODS  OF  EXAMINATION.  47 

sensation  found  frequently  in  the  joints  of  infants  and  children.  It 
is  detected  by  placing  the  palmar  surface  of  the  hand  upon  the  joint 
and  moving  the  extremity  which  enters  into  its  formation.  It  has 
been  found  by  the  writer  in  children  who  complained  of  no  definite 
joint-symptoms.  It  may,  under  these  conditions,  be  present  in  many 
joints  of  the  same  patient.  Some  infants  and  children  are  "  loose- 
jointed,"  that  is,  they  possess  a  facility  in  causing  subluxation  of  their 
joints  and  spontaneously  reducing  this  subluxation  with  a  snapping 
sound.  Faint  crepitus  is  found  in  children  who  have  had  an  attack 
of   rheumatism. 

Most  Common  Affections. — The  most  common  affections  to  look  for 
about  the  joints  are  simple  luxations;  syphilitic  disease;  osteomyelitis 
of  a  septic  or  infectious  nature;  scurvy  of  the  joints  or  epiphyses  in 
the  vicinity  of  the  joint;  rheumatism,  simple  acute  or  chronic,  and 
gonorrhoeal ;  tuberculous  joints,  especially  the  hip  ;  paralyses  (deltoid) 
of  muscles  about  a  joint;  deformities,  as  in  congenital  coxa  vara. 

The  Spine. — Anatomy. — ^^The  spinal  column  of  the  newborn  infant 
is  practically  devoid  of  natural  fixed  curves.  Fehling  found  that 
there  was  an  almost  imperceptible  curve  backward  (kyphosis)  in  the 
dorsal  region  and  a  slight  lordosis  in  the  lower  lumbar  region.  The 
latter  curve  was  more  marked  when  the  extremities  of  the  infant  were 
extended.  The  fixed  cuves  seen  in  the  cervical  dorsal  and  lumbar 
regions  later  in  life  begin  to  form  in  the  first  year.  They  are  fully 
fixed  by  the  seventh  year. 

Method  of  Examination. — The  purpose  of  examination  is  princi- 
pally to  discover  abnormal  curvatures  and  to  test  the  pliability  of  the 
vertebral  column.  In  other  words,  we  examine  for  rigidity  due  to 
disease  (Pott's).  The  patient  is  undressed  and  caused  to  stand 
erect.  The  index  finger  is  passed  down  the  vertebral  spinous  proc- 
esses, and  the  lines  of  these  processes  are  marked  out.  Any  ab- 
normal curve  is  thus  made  apparent.  Painful  areas  are  detected  by 
pressure  or  tapping  along  the  spinous  processes.  If  deformity  is 
present,  it  is  important  to  decide  whether  this  is  permanent  and 
combined  with  muscular  spasm  (Pott's)  or  due  to  rachitis.  For 
this  purpose  the  patient  is  placed  on  the  examining  table  face  down- 
ward. The  examiner  grasps  both  lower  extremities  at  the  ankles 
(Fig.  5).  The  palmar  surface  of  the  left  hand  is  laid  firmly  on 
the  junction  of  the  cervical  and  dorsal  spine.  The  extremities  are 
now  raised  and  hyperextended  with  the  right  hand.  If  the  spine 
is  supple  and  normal,  it  will  curve  backward  as  the  pelvis  is  raised 
toward  the  vertical.  If  there  is  deformity  due  to  Pott's  disease, 
this  will  persist.  Deformity  due  to  rachitis  will  disappear  under 
this  manipulation.  In  hip  disease,  if  the  left  hand  is  laid  on  the 
lumbar  region  and  the  above  hyperextension  gently  carried  out,  first 


48 


INFANCY  AND  CHILDHOOD. 


flexing  the  legs  back  at  a  right  angle  and  then  lifting  them  vertically, 
a  distinct  spasm  of  the  muscles  is  felt  (psoas  spasm)  (Fig.  6). 
Spinal  rigidity  is  also  made  apparent  by  causing  the  child  to  pick 
up  some  object  from  the  floor.  Under  conditions  of  disease  the 
patient  will  hold  the  spine  rigid  in  picking  up  the  object.     The  hips 

Fig.  5. 


Method  of  testing  mobility  and  pliability  of  the  spine. 


^,J34,yitjy^, 


and  knees  are  bent,  but  not  the  spine.  To  test  the  rigidity  at  the  out- 
set of  a  meningitis,  the  head  is  raised  as  the  patient  lies  recumbent. 
In  meningitis  the  rigidity  is  such  that  the  whole  trunk  can  be  raised 
by  placing  the  palm  underneath  the  occiput  and  gently  raising  the 

head. 

Fig.  6. 


^_2)'Yti'ir 


Method  of  testing  for  psoas  spasm. 


METHODS  OF  EXAMINATION.  49 

Muscular  Apparatus  and  Nervous  System. — Form. — Atrophy. — 
Atrophy  of  muscle  is  seen  in  any  disease  whicli  affects  tlie  trophic 
centres  of  muscle  in  the  cord.  Such  diseases  are  poliomyelitis,  and 
neuritis  following  traumatism,  diphtheria,  measles,  or  any  infectious 
disease.  Atrophy  is  seen  in  joint-affections,  especially  about  the  hip. 
In  the  latter  case,  not  only  disuse,  but  a  true  reflex  trophic  disturb- 
ance is  the  cause  of  the  atrophy. 

Hypertroyhy. — Hypertrophy  of  muscle  is  seen  in  cases  of  iso- 
lated congenital  hypertrophy  of  one  limb,  and  also  in  pseudohyper- 
trophic paralysis.  In  all  cases  of  change  of  volume  of  a  muscle  we 
compare  the  affected  limb  with  that  of  the  opposite  side  if  the  disease 
is  unilateral.  The  diseased  limb  is  measured  in  its  circumference  and 
compared  with  the  corresponding  healthy  limb. 

Reflexes. ^ — Patellar  lieflex. — We  shall  take  up  only  that  aspect  of 
the  subject  which  should  concern  the  practitioner  in  his  examination 
of  infants  and  children.  The  minutiae  of  electrical  muscle  and  nerve 
reactions  may  be  gleaned  from  works  treating  of  such  matters-  in 
detail. 

The  most  common  deep  reflex  is  that  of  the  patellar  tendon.  It 
is  obtained  by  placing  the  infant  in  a  recumbent  position,  supporting 
the  thigh  by  placing  the  left  hand  beneath  it,  and  raising  it  above 
the  level  of  the  body.  When  the  muscles  are  relaxed,  tap  the  patellar 
tendon  sharply  with  the  middle  finger  of  the  right  hand.  The 
procedure  is  similar  to  that  employed  in  percussion  of  the  chest.  Both 
limbs  are  examined  in  the  same  manner.  Children  who  can  sit  are 
placed  on  a  table  with  their  lower  extremities  dependent.  When 
the  attention  of  the  patient  is  fixed  upon  some  object  the  tendon  is 
tapped  sharply.     A  percussion-hammer  is  not  necessary. 

In  diseases  of  the  gray  matter  and  of  the  posterior  columns  of 
the  cord  with  trophic  disturbance  of  the  nerves  (poliomyelitis,  neu- 
ritis, Landry's  paralysis,  diphtheritic  paralysis)  the  patellar  reflex  is 
diminished  or  absent. 

In  brain  tumor  and  in  affections  of  the  lateral  columns  of  the 
cord  (multiple  sclerosis,  spastic  disease)  the  reflex  is  increased. 

The  reflex  is  unimpaired  in  cerebral  palsy,  Friedreich's  ataxia, 
and  in  cases  of  idiocy. 

Bahinski's  Reflex. — Babinski's  reflex  is  a  plantar  phenomenon 
found  in  some  forms  of  meningitis  (tuberculous),  and  in  diseases  in 
which  there  is  irritation  or  involvement  of  the  pyramidal  tracts.  On 
irritating  the  plantar  surface  of  the  foot  with  the  tip  of  the  index 
finger  there  is  a  vigorous  hyperextension  of  the  great  toe  with  spread- 
ing of  the  adjacent  toes.  Morse  has  shown  that  this  reflex  cannot  be 
relied  upon  in  children  under  two  years  of  age.  I  have  had  abundant 
opportunity  to  confirm  this  observation.     As  a  differential  diagnostic 

4 


50  '  INFANCY  AND  CHILDHOOD. 

sign,  the  Babinski  reflex  is  of  little  value,  although  I  have  observed  it 
to  be  present  more  frequently  in  the  tuberculous  forms  of  meningitis 
than  in  the  pyogenic  varieties. 

Kernig's  Symptom. — Kernig's  symptom  is  the  flexion  of  the  leg 
on  the  thigh  when  the  thigh  is  flexed  at  right  angles  to  the  trunk,  and 
is  found  in  children  suffering  from  any  form  of  meningitis,  and  in 
diseases  such  as  pneumonia  or  typhoid  fever  with  cerebral  symi^toms 
or  so-called'  meningism.  The  sign  has  the  same  characteristics  as  in 
the  adult.  In  infants  under  one  year  the  tendency  to  flex  the  leg  on 
the  thigh  is  normal.  In  these  subjects,  therefore,  the  presence  or 
absence  of  this  sign  possesses  no  significance. 

G-ait  or  Walk. — The  child  is  undressed,  so  that  the  feet  and  toes 
are  exposed,  and  is  caused  to  walk  to  and  fro  in  front  of  the  physician. 
The  gait  in  disease  may  be  ataxic,  spastic,  paretic,  or  wabbling. 

Ataxic  Gait. — Ataxic  gait  is  seen  in  children  suffering  from 
Friedreich's  ataxia,  or  from  tumor  involving  the  motor  centres  for 
the  lower  extremities.  The  gait  is  uncertain ;  patients  walk  as  if 
inebriated,  with  the  feet  wide  apart.  Incoordination  of  movement  is 
characteristic  of  all  these  cases.  We  must  in  all  cases  distinguish 
between  simple  muscular  weakness,  as  in  pseudohypertrophic  paraly- 
sis, and  convalescence  from  acute  disease,  such  as  fevers,  and  a  weak- 
ness combined  with  a  palpable  defect  in  the  power  of  coordinate 
action.  In  cases  of  cerebral  disease,  as  a  rule,  there  is  lack  of  coordi- 
nation elsewhere,  as  in  the  muscles  of  the  upper  extremities.  In  these 
cases  the  coordination  is  tested  in  older  children  by  telling  the 
patient  to  close  the  eyes,  and  directing  him  to  touch  the  tip  of  the 
nose  with  the  index  finger  of  the  right  hand  several  times  in  succes- 
sion. In  cases  of  ataxia  there  will  be  great  uncertainty  in  carrying 
out  this  manoeuvre.  In  diphtheritic  paralysis  there  may  be  combined 
with  a  real  weakness,  ataxia  or  incoordinate  movement.  If  we 
remember  that  in  these  cases  there  is  a  neuritis,  with  consequent 
atrophy  of  muscle  and  loss  of  reflex,  we  shall  not  commit  the  error 
of  overlooking  the  paralysis  in  our  desire  to  account  for  the  condi- 
tion present  as  a  simple  muscular  weakness  the  result  of  the  illness. 
In  these  cases  there  may  also  be  paralyses  of  the  trunk  muscles, 
causing  inability  to  assume  the  upright  posture.  In  ataxia  caused 
by  cerebral  tumor  there  is  in  certain  cases  a  crossed  hemiplegia 
(pons  tumor),  with  foot-clonus  and  paralysis  of  ocular  muscles,  which 
aid  in  the  diagnosis. 

Cerebellar  Tituljation. — In  cerebellar  tumor,  which  is  the  variety 
most  common  in  children,  there  are  at  the  outset,  in  most  cases, 
disturbances  of  the  gait  or  ataxia.  Th(>  patients  walk  in  an  uncer- 
tain manner,  generally  staggering  to  one  side.  In  severe  forms  of 
this  disease  the  patients  will  fall  to  one  side  if  not  protected.  •  The 


MANAGEMENT   AND   HYGIENE    OF   NORMAL   INFANT.  51 

cases  thus  far  recorded  all  show  early  involvement  of  the  optic, 
auditory,  and  other  cranial  nerves,  abducens  paralysis,  with  symp- 
toms of  vertigo. 

Spastic  Walk. — This  walk  is  so  characteristic  as  not  to  be  easily 
mistaken  for  anything  else.  It  is  found  in  all  forms  of  spastic 
paraplegia,  congenital  or  acquired.  There  is  not  only  actual  spasm, 
but  also  weakness  of  muscle.  There  are  other  phenomena  of  nervous 
disturbance,  such  as  increased  patellar  reflex  and  foot-clonus.  The 
patient  seems  to  drag  the  legs  in  walking.  Each  extremity  is  brought 
rigidly  forward,  the  toes  scraping  the  ground.  The  muscles  may  or 
may  not  be  well  nourished.  Electrical  contractility  may  or  may  not 
be  increased.  The  children  may  walk  cross-legged  (Gowers).  At 
first  there  is  inability  to  walk;  later  in  childhood  locomotion  is  pos- 
sible. In  certain  forms  the  spasm  of  the  extremities  is  so  great  as  to 
keep  them  in  constant  extension  at  the  knee ;  flexion  in  these  cases 
can  only  be  attained  with  great  expenditure  of  force. 

In  infants  and  children  who  cannot  walk  and  are  the  subject's 
of  spastic  paraplegia  the  characteristic  position  of  the  lower  extremi- 
ties may  be  made  aj^parent  by  supporting  the  patient  on  the  feef. 
In  all  of  these  cases,  as  soon  as  the  toes  touch  the  ground  the  reflex 
produces  the  characteristic  extension  of  the  limbs,  with  the  toes  or 
ball  of  the  foot  on  the  ground  and  the  heel  raised. 

In  very  young  infants  who  are  the  subjects  of  amaurotic  idiocy 
the  spastic  phenomena  are  sometimes  very  marked.  In  these  cases 
there  are  other  symptoms,  such  as  amaurosis  and  inability  to  hold 
the  head  upright,  the  presence  of  the  Tay-Kingdon  spot  in  the 
fundus  of  the  eye,  to  aid  in  the  diagnosis. 

Limping  Gait. — Joint-affections  cause  simply  a  limping  gait ;  a 
study  of  the  joint,  as  described  elsewhere,  will  aid  the  diagnosis. 

Infantile  Paralysis. — Infantile  paralysis,  or  cerebral  palsy,  at  the 
outset  causes  a  characteristic  dragging  of  the  extremity  if  the  paraly- 
sis is  not  complete.  Infants  in  whom  there  is  a  complete  loss  of 
power  in  one  or  both  lower  extremities  give  a  history  as  follows :  The 
infant  may  have  been  able  to  walk  or  stand ;  the  attack  suddenly  de^ 
prives  it  of  the  power  of  motion.  There  is  a  limp  extremity  on  one 
or  the  other  side,  with  rapid  atrophy  of  muscle  and  loss  of  reflex.  In 
cerebral  palsy  there  is  no  atrophy  and  the  tendon  reflex  is  present. 

The  methods  of  examining  the  mouth  and  special  organs  will  be 
considered  in  the  chapters  devoted  to  them. 

MANAGEMENT    AND    HYGIENE    OF    THE    NORMAL    INFANT. 

Taking  the  Infant  from  the  Mother  at  Birth. — As  soon  as  the 
infant  is  born  and  pulsation  in  the  cord  has  ceased,  the  cord  is  tied 


52  '  INFANCY  AND  CHILDHOOD. 

and  the  physician  places  the  newborn  in  the  care  of  the  nurse.  The 
tying  of  the  umbilical  cord  should  be  performed  rapidly,  and  the 
nurse,  for  this  purpose,  should  have  at  hand  a  piece  of  sterilized  tape 
or  broad  binding-silk  and  scissors  which  have  been  boiled  in  water 
and  then  carefully  wrapped  in  a  clean  towel.  It  is  not  necessary  to 
use  silk  which  has  been  soaked  in  antiseptic  solutions,  such  as  car- 
bolic acid,  for  the  infant  is  peculiarly  susceptible  to  these  drugs.  I 
have  seen  an  infant  whose  cord  was  tied  with  silk  saturated  with  a 
very  strong  solution  of  carbolic  acid  who,  within  a  few  hours  after 
birth,  showed  signs  of  the  action  of  the  drug.  The  sterilized  tape  and 
scissors  should  be  in  readiness  for  the  physician,  as  searching  for  the 
tape  or  scissors  causes  an  inexcusable  delay.  A  warmed  piece  of  soft 
blanket  is  wrapped  about  the  infant  at  once.  As  is  well  known,  the 
infant  at  birth  cries  lustily ;  nature  intends  that  it  should  be  so  at  this 
time  in  order  that  the  lungs  may  be  filled  with  air. 

Umbilical  Cord. — Tying  of  the  Cord. — The  physician  should  tie 
the  cord,  as  has  been  stated,  with  a  piece  of  sterilized  tape  or  broad 
binding-silk,  about  an  inch  or  an  inch  and  a  half  from  the  body,  after 
the  pulsation  of  the  cord  has  ceased,  unless  some  feature  in  connection 
with  labor  indicates  a  more  rapid  procedure.  After  the  initial  bath 
the  cord  is  inspected  to  see  that  the  first  ligature  is  still  intact.  Ahl- 
feld,  after  having  placed  the  primary  ligature,  reties  the  cord  close 
to  the  abdominal  wall,  though  this  seems  to  be  unnecessary.  If  the 
ligature  is  still  in  place  and  there  is  no  hemorrhage,  the  stump  of  the 
cord  and  the  surrounding  tissues  are  washed  with  strong  alcohol,  and 
a  sterilized  dry  gauze  pad  with  inclosed  absorbent  cotton  is  folded 
over  the  umbilical  stump.  This  is  held  in  place  with  a  clean  body- 
binder.  The  first  dressing  is  not  removed  until  the  stump  of  the  cord 
has  fallen  off  and  the  umbilicus  has  healed,  unless  there  is  some  in- 
dication for  its  renewal,  such  as  the  soiling  of  the  dressing  by  the 
urine  of  the  infant  (Ahlfeld). 

Another  method  of  dressing  the  cord  is  to  form  a  pad  of  absorb- 
ent gauze  four  or  five  layers  thick,  about  three  inches  square,  cutting 
a  small  opening  in  the  centre.  The  stump  of  the  cord  is  passed 
through  this  opening  and  the  gauze  folded  over  the  stump.  The 
dressing  is  secured  with  an  ordinary  body-binder.  This  dressing, 
also,  is  not  disturbed  unless  it  is  soiled  by  the  urine  of  the  infant. 

Stump  of  the  Cord. — The  stump  of  the  umbilical  cord  dries  up 
and  falls  off  from  the  sixth  to  the  tenth  day.  It  may  fall  off  as 
early  as  the  third  or  as  late  as  the  fourteenth  day.  In  premature 
or  weakly  infants  this  process  is  delayed.  Even  in  healthy  infants  a 
delay  may  occur  which  has  no  pathological  sig-nificance.  When  the 
stump  of  the  cord  drops  off  there  remains  a  flat,  granulating  surface, 
which  cicatrizes,  and  after  a  time  takes  on  the  appearance  of  the 


MANAGEMENT    AND   HYGIENE    OF   NORMAL   INFANT.  O'S 

neighboring  skin.  Occasionally,  however,  the  site  of  the  stump  takes 
the  form  of  a  small  pea-like  body,  sometimes  having  a  thin  pedicle. 
This  is  made  up  of  granulation  tissue  and  has  been  called  fungus  of 
the  umbilicus.  It  will  be  discussed  elsewhere,  l^ormally  there 
should  be  no  protrusion  of  the  umbilicus,  even  when  the  baby  cries. 

The  drying  or  mummification  of  the  stump  of  the  umbilical  cord 
is  a  purely  physical  process,  and  depends  more  or  less  on  the  dryness 
of  the  dressing  on  the  stump  of  the  cord.  When  the  stump  of  the 
cord  remains  dry,  but  few  bacteria  are  found  in  the  tissues ;  if,  how- 
ever, as  in  very  exceptional  cases,  moist  gangrene  of  the  stump  takes 
place,  staphylococci  and  streptococci  in  large  numbers  appear  in  the 
stump  and  the  immediate  vicinity.  The  stump  of  the  cord  is  thrown 
off  by  a  sort  of  reactionary  inflammation  at  the  point  of  juncture  of 
the  amnion  sheath  of  the  cord  and  the  skin.  A  few  hours  after  birth 
the  capillary  network  in  this  vicinity  is  seen  to  become  congested. 
The  amnion  first  separates,  then  the  arteries,  and  finally  the  vein, 
leaving  a  granulating  base  at  the  umbilicus. 

Bathing.— First  Bath. — The  question  has  been  much  debated  as 
to  whether  an  infant  should  be  bathed  immediately  after  birth  or 
whether  the  body  should  be  simply  anointed  with  vaseline  or  olive  oil, 
wiped  off,  and  not  bathed  until  the  stump  of  the  cord  has  fallen  off 
Whatever  objection  there  is  to  bathing  premature  infants,  this  cannot 
hold  with  infants  at  full  term.  The  bath  is  cleansing.  The  lochial 
discharge  of  the  mother  if  allowed  to  remain  in  contact  with  the  skin 
is  apt  to  decompose,  and  a  source  of  infection  is  at  once  presented. 

The  most  convenient  form  of  bath-tub  for  the  infant,  if  it  can  be 
obtained,  is  that  constructed  of  rubber  sheeting.  It  obviates  placing 
under  the  infant  any  blankets,  as  must  be  done  in  a  bath-tub  made 
of  metal.  These  bath-tubs  are  constructed  so  as  to  have  a  certain  con- 
venient height  from  the  floor.  They  hold  heat  better  than  the  metal 
bath-tub. 

The  temperature  of  the  room  in  which  the  newborn  infant  is 
bathed  should  be  70°  to  72°  F.  The  bath-tub  should  be  situated,  if 
possible,  near  an  open  fire,  to  insure  warmth. 

At  birth  the  infant  is  covered  with  a  white  substance,  the  vernix 
caseosa,  which  must  be  carefully  removed,  and  to  this  end  the  body 
is  anointed  with  vaseline  or  olive  oil,  the  latter  being  preferable  to 
vaseline,  which  may  irritate  the  skin.  When  the  infant  is  anointed 
it  should  be  exposed  part  by  part  only,  in  order  to  guard  against  rapid 
reduction  of  body-temperature,  and  care  should  be  taken  not  to  dis- 
place the  ligature  or  roughly  handle  the  stump  of  the  cord,  lest 
hemorrhage  result.  The  first  bath  is,  therefore,  a  scientific  function ; 
it  cleanses  and  protects  the  infant  from  present  and  future  auto- 
infection.     The  water  in  which  the  infant  is  bathed  should  be  boiled. 


54  INFANCY  AND  CHILDHOOD. 

in  order  to  destroy  any  extraneous  source  of  infection,  for,  as  will  be 
seen  later,  the  bath-water  has  been  the  cause  of  ei3idemics  among  the 
newborn,  especially  in  hospital  service.  In  private  practice  this 
danger  does  not  obtain  to  the  same  extent  as  in  institutions. 

The  infant  should  be  bathed  rapidly,  and  at  the  same  time  in  a 
painstaking  and  gentle  manner.  The  water  of  the  bath  should  be 
100°  F.,  and  some  additional  warm  water  should  be  at  hand  in  order 
that  the  temperature  of  the  bath  water  may  be  maintained  at  this 
point.  The  infant  is  placed  in  the  bath,  rapidly  washed  with  glycerin 
soap,  and  lifted  out  and  placed  in  a  warm  blanket.  The  depth  of  the 
water  in  the  tub  should  be  just  enough  to  cover  the  body.  The  head 
is  supported  above  the  water  by  the  disengaged  hand  of  the  nurse. 
The  infant  cannot  slip  out  of  the  arms  of  the  nurse.  While  in  the 
bath,  the  infant  is  constantly  but  gently  rubbed,  and  when  taken  from 
the  bath  should  not  be  blue  or  in  the  least  chilled.  Drying  the  infant 
is  best  performed  on  the  knees  of  the  nurse,  part  by  part,  so  as  not  to 
expose  the  infant's  whole  body  at  one  time.  The  cord  is  dressed  as 
above  described  and  the  binder  applied.  All  clothing,  including  the 
binder  of  the  newborn  infant,  should  be  made  of  soft  flannel  or  pure 
wool, 

Daily  Bath. — There  has  been  some  discussion  as  to  whether  an 
infant  should  be  bathed  daily,  after  the  first  bath,  before  the  separa- 
tion or  falling  off  of  the  stump  of  the  umbilical  cord.  It  has  been 
demonstrated  that  infants  who  are  not  bathed  in  the  first  week  lose 
less  in  weight  than  those  who  are  bathed.  It  is  best,  therefore,  in 
order  to  avoid  infection  of  the  umbilical  wound,  to  favor  mummifica- 
tion of  the  cord,  as  well  as  to  conserve  the  weight  of  the  infant, 
not  to  give  a  full  bath,  after  the  first  bath  detailed  above,  until  the 
umbilical  wound  has  healed  and  the  stump  of  the  cord  has  separated. 
When  this  has  taken  place  the  infant  is  bathed  daily ;  up  to  that  time 
it  is  washed  twice  daily,  with  a  view  to  cleanliness.  If  the  dressing 
on  the  umbilical  stump  has  become  soiled  with  urine,  or  otherwise, 
it  is  changed ;  but  unless  this  indication  exists  the  first  dressing  is 
left  undisturbed. 

The  best  time  for  the  bath  is  in  the  forenoon,  one  hour  after 
nursing.  The  temperature  of  the  water  of  the  infant's  bath  should 
not  be  below  99°  or  100°  F.  during  the  first  ten  days;  95°  F.  dur- 
ing the  first  month  of  infancy;  and  90°  F.  after  the  sixth  month. 
It  has  been  proposed — on  grounds  which  are  somewhat  obscure  and 
not  founded  on  physiological  facts — to  harden  the  infant  by  means 
of  a  gradual  reduction  of  the  temperature  of  the  bath-water  until, 
even  with  an  infant  below  one  year,  the  bath-water  is  quite  cool. 
Such  a  procedure  does  not  harden  the  infant ;  on  the  contrary,  it  has 
been  shown  tliat  it  is  directly  detrimental  to  his  growth  and  well- 


MANAGEMENT    AND   HYGIENE    OF   NOEMAL   INFANT.  55 

being.  Delicate  infants,  even  those  born  at  full  term,  may  by  such 
a  process  of  hardening  contract  a  bronchitis,  or  even  some  more 
dangerous  affection  of  the  lung. 

The  details  of  the  daily  bath  are  much  the  same  as  those  de- 
scribed with  the  newborn  infant.  The  use  of  a  sponge  in  bathing 
is  not  cleanly  or  desirable.  A  soft  piece  of  linen  or  muslin  or  so- 
called  washcloth  is  much  to  be  preferred,  as  it  can  be  easily  cleansed 
and  boiled.  After  the  bath  the  infant  is  taken  from  the  water  and 
placed  in  a  soft,  warm  blanket  or  bath  robe,  carefully  dried  and 
powdered.  Powder  is  applied  to  the  axillae,  groins,  buttocks — where 
surfaces  come  in  contact.  The  general  surface  of  the  body  is  not 
powdered  unless  some  indication  exists. 

Premature  Infants,  and  Infants  who  are  Under  Weight. — Infants 
born  prematurely  or  those  who  weigh  six  pounds  or  less,  even  though 
born  at  full  time,  should  not  be  bathed  as  above  described,  but  are 
best  washed  part  by  part  with  warm  water  once  a  day  until  the 
weight  has  reached  the  normal  limits.  These  puny  infants  are  par- 
ticularly susceptible  to  reduction  of  temperature.  In  fact,  the  rectal 
temperature  in  such  infants  is  always  low,  and  any  bath,  even  a 
warm  one,  will  reduce  the  temperature  still  more  and  may  result  in 
serious  chilling  of  the  body. 

Hardening. — It  will  be  seen  from  what  I  have  said  that  I  do  not 
believe  in  the  so-called  hardening  process  as  applied  to  children.  I 
have  seen  children,  whose  mothers  took  a  pride  in  bathing  them  with 
cold  water,  who  remained  pale,  stunted  in  growth,  nervous,  even  with 
a  flabby  musculature,  notwithstanding  a  daily  regimen  of  cold  water 
which  Avas  intended  to  have  a  tonic  effect,  both  on  the  general  nervous 
system  and  physical  development  of  the  child.  I  have  rarely  found, 
at  least  in  this  climate,  that  any  other  temperature  for  bathing  was 
indicated  but  that  which  has  been  mentioned  above.  A  very  excel- 
lent guide  as  to  the  proper  effect  of  any  form  of  bathing  on  an  infant 
is  the  so-called  reaction  in  and  immediately  after  the  infant  is  taken 
out  of  the  bath.  In  the  bath  and  after  bathing  the  infant  should  be 
warm  on  the  surface  and  present  a  ruddy  appearance.  If  during  or 
after  a  bath  the  infant  is  cyanosed  and  the  surface  of  the  body  is  cool, 
we  will  conclude  that  the  bath,  at  whatever  temperature  it  is  given,  is 
not  adapted  to  the  infant. 

Eyes.- — In  a  maternity  service,  where  numbers  of  women  are  de- 
livered and  there  is  danger  of  one  infant  being  infected  by  another, 
it  is  customary  to  instil  into  each  eye  at  birth  a  drop  of  a  2  per 
cent,  solution  of  nitrate  of  silver.  This  is  done  as  a  prophylactic 
measure  against  gonorrhoeal  ophthalmia,  a  disease  which  has  been 
proved  to  be  a  great  etiological  factor  in  the  causation  of  blindness. 
In  private  practice,  however,  this  is  scarcely  necessary   (see  Oph- 


56  INFANCY  AND  CHILDHOOD. 

thalmia  J^eonatorum),  especially  if  we  are  acquainted  with  the  con- 
dition of  the  mother  and  no  vaginal  discharge  has  been  present  pre- 
vious to  labor.  If,  however,  there  has  been  a  vaginal  discharge 
before  labor,  it  is  well  either  to  apply  the  Crede  method  and  instil 
a  drop  of  a  2  per  cent,  solution  of  nitrate  of  silver  into  the  eye,  or  to 
carry  out  the  prophylactic  measure  of  Kaltenbach,  described  in  the 
section  on  Blennorrhoeal  Ophthalmia. 

The  eyes  during  infancy  need  no  attention  other  than  that  cus- 
tomary in  the  adult — cleanliness.  Any  slight  discharge  from  the 
eye  indicates  a  conjunctivitis.  The  nearer  this  conjunctivitis  occurs 
to  birth,  the  more  we  should  be  on  guard  for  detection  of  a  gonor- 
rhoeal  process.  It  is  always  wise,  therefore,  as  soon  as  any  secre- 
tion of  pus  is  detected  in  the  eyes  of  the  newborn  infant,  to  examine 
this  pus  for  microorganisms  of  a  specific  nature.  Any  swelling  of 
the  conjunctiva  or  the  lids  should  put  us  on  our  guard  against  gon- 
orrhoea! infection. 

Method  of  Taking  the  Body-temperature  of  the  Infant. — The 
temperature  of  infants  and  children  is  always  taken  in  the  rec- 
tum ;  but  if  the  child  is  above  five  years  of  age  we  may,  under  certain 
conditions,  take  an  axillary  temperature.  Some  children  are  terri- 
fied at  the  sight  of  a  thermometer ;  others  have  an  innate  mod- 
esty, which  it  is  the  duty  of  the  physician  to  respect,  and  which 
precludes  the  taking  of  a  rectal  temperature.  If  the  indication  is 
not  pressing,  therefore,  an  axillary  temperature  may  be  taken  in 
older  children  in  the  same  manner  as  in  the  adult. 

It  is  well  in  dealing  with  children  to  teach  the  parents  how  to 
use  the  thermometer.  In  this  way  each  child  may  have  its  o^vn 
thermometer,  whether  it  is  used  in  the  rectum,  the  axilla,  or  the 
mouth.  This  is  not  only  convenient  for  the  physician,  but  is  entirely 
proper,  especially  as  applied  to  children,  for  thermometers  cannot  be 
thoroughly  disinfected,  and  it  is  certainly  objectionable  for  a  phy- 
sician to  go  from  one  little  patient  to  another,  introducing  the  same 
thermometer  into  the  rectum. 

In  introducing  the  thermometer  into  the  rectum,  the  infant  or 
child  should  be  laid  on  the  side.  The  bulb  of  the  themiometer 
is  anointed  with  vaseline  or  olive  oil,  the  buttocks  are  gently  sep- 
arated with  the  fingers  of  the  left  hand,  and  with  the  right  hand 
the  bulb  of  the  thermometer  is  carefully  insinuated  into  the  rectum. 
The  infant  or  child  is  continued  on  the  side  for  three  minutes.'  Some 
thermometers  register  the  temperature  in  less  time.  The  thermometer 
is  then  removed,  and  after  reading  the  register  the  physician  should 
carefully  cleanse  the  thermometer,  before  proceeding  further,  with  a 
piece  of  cotton  first,  then  with  a  fresh  piece  of  cotton  moistened  with 
ether  and  then  alcohol,  and  finally  with  a  1:  2000  solution  of  cor- 


MANAGEMENT   AND   HYGIENE    OF   NOBMAL    INFANT.  57 

rosive  sublimate  or  a  0.5  per  cent,  solution  of  formalin.  In  private 
practice  this  paraphernalia  is  not  always  at  hand,  and  the  physician 
can  see  at  once  the  utility  of  teaching  the  parents  to  have  a  thermom- 
eter in  the  house  for  the  use  of  the  child  rather  than  that  he  should 
imperfectly  cleanse  his  own  thermometer  and  use  it  on  another  pa- 
tient. In  children's  hospitals  this  question  of  individual  thermom- 
eters is  of  great  importance,  and  no  children's  service  can  be  con- 
ducted without  danger  of  infections  arising  unless  each  patient  has 
his  or  her  own  thermometer. 

Temperatures  should  be  taken  in  mild  cases  of  illness  and  in 
convalescence  three  times  daily;  in  protracted  and  serious  illness, 
such  as  pneumonia  or  typhoid  fever,  every  three  hours  throughout 
the  twenty-four. 

Diapers. — The  diaper  should  be  made  of  an  absorbent  material, 
such  as  well-washed  soft  muslin  or  linen,  and  should  be  about  two 
yards  square.  It  is  first  folded  in  the  middle,  then  in  three-cornered 
fashion,  refolded,  and  thus  applied  to  the  infant.  A  diaper  should 
not  be  covered  with  a  rubber  protection  except  during  travel,  inas- 
much as  under  these  conditions  the  diaper  becomes,  if  moistened,  a 
species  of  poultice  and  intertrigo  results,  as  well  as  eczematous  erup- 
tions of  the  buttocks.  Diapers  should  be  applied  warm  and  dry.  A 
moist  diaper  will  sooner  or  later  cause  a  skin  eruption.  A  diaper 
moistened  with  urine  should  not  be  dried  and  used  again  on  the  in- 
fant, for  by  this  method  the  salts  of  the  urine  are  crystallized  in  the 
meshes  of  the  diaper  fabric  and  will  irritate  the  skin.  Diapers  when 
soiled  should  be  placed  in  a  covered  utensil  sold  in  the  shops  for  this 
purpose.  Before  washing  the  diaper  the  excess  of  faeces  should  be 
removed.  Diapers  should  be  boiled  in  plain  water,  as  soda  in  the 
water  may  irritate  the  buttocks,  and  should  be  washed  by  hand,  not 
with  the  mandril,  otherwise  the  fffices  and  discharges  cannot  be 
removed  thoroughly. 

After  a  movement  the  child  is  dried  gently  with  a  piece  of  soft 
linen,  sponges  not  being  used,  carefully  powdered,  and  a  new  diaper 
applied.  Diapers,  if  soiled,  should  not  be  put  into  a  disinfecting 
solution.  On  the  contrary,  there  is  a  positive  objection  to  this,  as 
diapers  permeated  with  drugs  may  cause  irritation  of  the  skin  of  the 
buttocks.  After  changing  the  diapers,  the  nurse's  hands  and  finger- 
nails should  be  cleansed  with  brush  and  file.  This  toilet  of  the 
hands  and  finger-nails  is  very  important,  even  with  breast-fed  in- 
fants, since  the  neglect  of  this  function  will  result  in  a  contamina- 
tion of  the  breast  nipple  or  food  with  fsecal  bacteria.  Even  the 
infant's  own  faeces  may  cause  serious  intestinal  disturbance  if  rein- 
troduced in  the  above  manner  into  the  stomach  and  intestine. 

Care  of  the  Genitalia.— The  care  of  the  genitalia  in  male  and 


58  INFANCY  AND  CHILDHOOD. 

female  infants  is  qnite  important,  and  it  is  surprising  to  see  how 
such  a  simple  matter  is  neglected  by  the  mother  and  nurse.  In 
female  infants  and  children  during  the  bath  the  labia  should  be 
washed,  gently  separated,  and  the  parts  beneath  laved  with  water. 
After  the  bath  these  parts  should  be  carefully  dried,  but  not  powdered. 
It  is  a  very  common  practice  to  powder  the  parts  beneath  the  labia 
majora  in  female  infants.  This  custom  causes  considerable  irritation 
around  the  introitus  vaginae,  as  a  result  of  the  powders  settling  on 
the  parts.  If  these  parts  are  not  powdered,  but  simply  dried  after 
the  bath,  they  will  remain  in  a  normal  condition,  and  an  accumulation 
of  smegma  will  be  avoided. 

In  male  infants  the  prepuce  should  be  retracted  daily  and  the 
parts  bathed  with  ordinary  water.  In  this  way  accumulation  of 
smegma,  and  balanitis  will  be  prevented.  It  is  not  necessary  to  use 
medicated  solutions,  such  as  boric  acid,  for  this  purpose.  In  boys 
the  scrotum,  buttocks,  and  adjacent  parts  should  be  powdered. 

Play;  Fondling. — It  must  not  be  forgotten  that  the  average  in- 
fant's stomach  is  easily  upset,  and  that  any  kind  of  pressure  on 
the  abdomen  is  often  a  very  effective  way  of  emptying  the  stomach. 
After  feeding,  therefore,  the  infant  should  lie  quietly  in  its  crib  and 
not  be  handled  or  fondled.  Unless  this  rule  is  followed,  vomiting 
after  nursing  will  quite  frequently  occur. 

It  should  be  remembered  that  too  much  play  is  apt  to  tire  an 
infant  as  much  as  it  would  an  adult.  Infants  who  are  played  with 
and  fondled  to  excess  are  tired,  restless,  irritable,  and  sometimes  do 
not  sleep.  There  is  no  rule  to  be  applied,  but  moderation  is  to  be 
followed  in  these  things  as  in  all  others  concerning  the  infant's 
pleasure.  Children  should  not  be  allowed  too  much  intercourse  with 
adults,  as  this  is  also  apt  to  have  a  deleterious  effect.  Children  should 
play  with  children.  Adults  should  limit  their  play  and  contact  with 
children  as  much  as  possible. 

Sleep. — An  infant  in  perfect  health  spends  most  of  the  time  in 
sleep  when  it  is  not  nursing.  Unless  its  attention  is  engaged  by 
others,  it  will  not  play  in  the  early  months  of  infancy.  After 
nursing,  an  infant  falls  asleep,  generally  on  the  breast.  Therefore, 
if  an  infant  cries  or  is  restless  after  nursing,  there  is  something  at 
fault.  Older  children  should  slee])  in  the  afternoon  for  one  hour, 
after  the  midday  meal.  This  should  be  especially  insisted  upon 
with  children  who  have  a  nervous  temperament.  If  such  children 
do  not  attain  an  early  habit  of  sleep  in  the  afternoon  they  will  be 
restless  at  night,  and  finally  develop  symptoms  of  neurasthenia. 

Bed. — The  best  bed  for  the  newborn  infant  is  one  in  the  form  of  a 
bassinet.     The  infant  certainly  should  not  sleep  in  the  bed  with  the 


MANAGEMENT   AND   HYGIENE    OF   NOBMAL   INFANT.  59 

mother  or  nurse,  for,  aside  from  the  clanger  of  so-called  overlying, 
the  infant  is  liable  to  become  infected  with  the  discharges  of  the 
mother;  and  in  a  breast-fed  infant  there  is  always  a  temptation  to 
give  the  breast  to  the  child  at  night  whenever  it  is  restless.  Bad 
habits  therefore  result.  Aside  from  this,  an  infant  will  be  restless 
unless  trained  to  sleep  in  its  own  bed. 

The  mattress  of  the  bed  should  consist  of  a  hair  cushion  pro- 
tected by  a  rubber  draw-sheet.  Over  this  is  placed  a  bed-pad,  and 
over  this  the  bed-sheet.  After  the  fourth  month  an  infant  may  be 
placed  in  a  crib.  For  restless  children  cribs  are  made  with  high 
sides,  so  that  they  may  not  fall  out.  Rocking  bassinets  or  cribs 
are  undesirable.  An  infant  accustomed  to  a  rocking-crib  or  cradle 
will  not  fall  asleep  unless  rocked,  and  the  mother  or  nurse  becomes 
a  slave  to  the  crib.  If  a  baby  in  early  infancy  cries  without  any 
apparent  cause  just  as  it  is  placed  in  the  crib  from  ,the  mother's  or 
nurse's  arms,  it  is  best  not  to  take  it  up  immediately,  for,  unless 
this  habit  is  broken  in  early  infancy,  an  infant  will  refuse  to  be 
pacified  unless  taken  up  several  times  in  the  twenty-four  hours. 

The  physician  may  be  consulted  concerning  the  pillow  for  the 
infant,  as  to  whether  it  should  be  made  of  hair  or  down-feathers.  It 
is  well  for  the  young  practitioner  to  know  that  a  pillow  made  of 
the  finest  curled  hair  is  really  more  comfortable  than  a  down-pillow. 
When  placed  under  the  infant's  head,  the  pillow  should  reach  well 
beneath  the  shoulders,  so  that  the  head  and  shoulders  are  supported 
together.  The  custom  of  not  using  the  pillow  for  the  infant  allows 
the  head  to  come  in  direct  contact  with  the  mattress,  a  very  uncom- 
fortable position,  and  one  which  inevitably  results  with  careless 
mothers  or  nurses  in  a  slight  erosion  at  the  back  of  the  head,  over  the 
occiput. 

So-called  pacifiers  made  of  rubber  or  muslin  should  never  be 
used  in  the  nursery.  They  are  undesirable  and  unnecessary,  and 
if  not  used  will  not  be  in  demand. 

Nursery. — The  temperature  of  the  room  in  which  the  infant 
passes  its  days  should  be  carefully  maintained  at  from  68°  to  70°  F. 
Variations  in  the  tenifterature  of  the  room  not  only  chill  the  infant, 
but  interfere  with  its  growth  and  nutrition.  Drafts  are  reprehen- 
sible. The  air  of  the  room  should  have  no  odor,  and  we  should 
ventilate  indirectly  from  another  room  which  is  warmed.  Incense 
should  never  be  used  to  cover  up  an  odor.  The  nursery  should  be 
well  lighted,  as  well  as  capable  of  ventilation.  An  open  fireplace 
aids  the  ventilation  considerably,  and  in  damp  weather  dries  and 
warms  the  atmosphere  as  well  as  ventilates  the  room. 

The  floor  of  the  nursery  should  be  made  of  hard  wood  or  painted 
and  covered  with  rugs.     Carpets  are  not  hygienic.     They  must  be 


60  •  INFANCY  AND  CHILDHOOD. 

swept  in  situ;  whereas  rugs  can  be  taken  out,  dusted,  and  aired. 
The  crib  should  be  protected  from  the  open  window  by  means  of  a 
screen.  During  infancy,  up  to  the  twelfth  month,  the  temperature 
of  the  nursery,  both  day  and  night,  should  be  kept  at  the  same 
point.  There  is  no  reason  why  the  temperature  should  be  lower  at 
night  than  during  the  day,  as  is  customary  in  the  sleeping-room  of 
the  adult.  When  the  infant  is  in  the  open  air,  the  nursery  should 
be  thoroughly  ventilated  for  at  least  an  hour  a  day.  With  premature 
children,  however,  we  must  be  more  careful  and  keep  the  temperature 
at  a  slightly  higher  point  than  the  above.  Or,  if  we  have  the  room 
at  70°  F.,  such  children  should  be  aided  in  maintaining  the  body- 
warmth  by  means  of  warm  bottles  placed  underneath  the  blankets 
in  the  crib,  but  not  necessarily  close  to  the  body. 

Open  Air. — The  infant  may  be  taken  into  the  open  air  three  weeks 
after  birth  in  the  summer  season  and  four  weeks  after  during  the 
winter,  early  spring,  and  fall.  I  have  consistently  advised  that  four 
weeks  after  birth,  if  the  weather  is  not  too  cold,  the  newborn 
infant  may  be  allowed  an  outdoor  airing.  I  have  seen  no  bad  results 
follow  from  this  advice.  If  the  weather  is  exceedingly  cold,  com- 
mon sense  would  dictate  that  an  infant  should  be  kept  indoors.  A 
daily  open-air  exposure  is  always  allowable  in  good  weather,  provided 
the  infant  be  warmly  clad,  especially  in  the  winter  time,  so  as  to  run 
no  danger  of  chilling.  If  an  infant  shows  a  tendency  to  be  easily 
chilled  when  taken  into  the  open,  warm  bottles  should  be  placed  under- 
neath the  covers  of  the  baby  carriage. 

Infants  should  be  protected  from  the  direct  rays  of  the  sun, 
inasmuch  as  they  burn  and  tan  very  readily.  Tanning  of  the  skin, 
or  sunburn,  is  not  necessary  to  the  health  of  the  infant.  A  physician 
will  frequently  be  asked  whether  sleeping  in  the  open  air  is  injurious 
to  the  infant.  It  certainly  is  not,  provided  the  infant  is  well  pro- 
tected in  the  manner  described  above.  Some  infants  fall  asleep 
immediately  on  coming  into  the  open.  We  could  scarcely  keep  such 
infants  awake,  and  nature  simply  indicates  to  us  in  this  way  that 
the  open  air  is  a  tonic  to  the  general  nervous  system.  In  large 
cities,  both  in  summer  and  winter,  the  face  should  be  protected 
by  a  veil  when  the  infants  are  taken  into  the  open.  In  the  country 
this  is  especially  necessary  if  mosquitoes  and  flies  are  in  the  vicinity. 
Children  who  are  running  about  should  not  wear  short  stockings  if 
the  locality  is  infested  with  mosquitoes  or  insects.  There  is  nothing 
particularly  hygienic  in  the  custom  of  wearing  short  stockings,  and 
it  exposes  the  children  to  the  danger  of  infection,  not  only  by 
mosquitoes  (malaria),  but  by  dangerous  insects,  such  as  spiders. 

Clothing. — The  clothing  of  the  infant  should  consist  of  a  chemise 
of  wool  next  the  skin.     Over  this  there  should  be  a  loose  garment. 


MANAGEMENT   AND   HYGIENE    OF   NORMAL   INFANT.  61 

either  wool  or  flannel,  reaching  from  the  shoulder  to  below  the  feet, 
and  sufficiently  long  to  allow  it  to  be  folded  upward.  Garments 
should  not  restrict  the  chest  in  the  old-fashioned  way.  The  chemise 
should  be  made  of  gauze  weight  in  summer  and  slightly  heavier  in 
the  winter.  Some  infants  cannot  tolerate  the  contact  of  wool  with 
the  skin,  because  it  causes  an  eruption  of  sudamina ;  in  such  cases  it 
is  well  to  place  between  the  skin  and  the  woolen  garment  a  fine-linen 
chemise. 

Body-'binder. — It  is  customary  to  provide  the  newborn  infant  with 
a  body-binder  made  of  soft,  white,  thin  Shaker  flannel,  five  inches 
wide  and  sufiiciently  long  to  pass  two  or  three  times  around  the  body. 
It  should  be  secured  with  strings,  and  not  with  pins,  nor  should  it  be 
sewed  on  the  body.  It  is  useful  at  first  in  retaining  the  dressing  of 
the  cord  in  place,  and  later  on  in  supporting  the  umbilicus  during 
straining  or  crying.  The  binder  is  discarded  when  the  infant  first 
makes  attempts  to  stand.  This  usually  occurs  at  the  seventh  month. 
The  binder  then  loses  its  utility,  inasmuch  as  the  umbilical  opening 
is  naturally  closed  and  supported  by  the  muscular  action  of  the  recti 
muscles.  It  is  customary,  however,  to  substitute  for  the  binder,  when 
it  is  discarded,  a  so-called  knitted  flannel  band,  sold  in  the  shops  for 
this  purpose. 

Skin.' — The  precautions  which  should  be  observed  in  drying  the 
skin  after  the  bath  have  already  been  mentioned.  Dusting-powders 
that  contain  perfume  should  be  avoided.  Dusting-powder  is  applied 
with  a  puff  of  absorbent  cotton  in  preference  to  a  powder-puff.  This 
absorbent  cotton  can  be  thrown  away  and  a  new  pledget  used  at  each 
dressing.    To  prevent  caking,  any  excess  of  powder  should  be  removed. 

If  the  skin  is  subject  to  sudamina  in  the  summer,  a  handful  of 
bran  is  added  to  the  water,  or,  what  is  preferable,  the  bran  is  put 
into  a  gauze  bag,  moistened  and  expressed  in  the  water  of  the  bath 
until  the  water  becomes  turbid.  Salt  water  irritates  the  skin  of 
these  infants  and  should  not  be  used. 

Mouth. — It  was  formerly  customary  to  wash  the  mouth  of  the 
infant  thoroughly  either  after  each  feeding  in  bottle-fed  infants,  or 
two  or  three  times  daily  in  breast-fed  infants.  There  is  really  no 
scientific  indication  for  doing  this  if  the  rubber  nursing  nipples  and 
the  bottles  used  for  artificially  fed  infants  are  kept  scrupulously 
clean;  and  the  mother's  or  nurse's  breast  nipple  with  the  breast-fed 
infant  be  cleansed  with  a  solution  of  boric  acid  before  and  after  each 
nursing.  Sprue  or  stomatitis  will  thus  be  avoided.  Before  the 
eruption  of  the  teeth,  the  natural  secretions  of  the  mouth  are  quite 
sufficient  to  keep  the  mouth  clean. 

The  nurse  should  not  introduce  the  finger  into  the  mouth  of  the 
infant,   either   to   cleanse  it  or   otherwise,   under   ordinary  circum- 


62  INFANCY  AND  CHILDHOOD. 

stances.  I  have  seen  stomatitis,  both  simple  and  gonorrhoeal,  more 
commonly  Bednar's  aphthae,  cansed  by  the  introduction  of  the  finger 
into  the  mouth  for  the  purpose  of  cleansing  the  same. 

After  the  teeth  have  appeared  they  may  be  kept  clean  by  washing 
once  a  day  with  cotton  moistened  with  boric  acid  solution.  The  best 
time  is  in  the  morning,  after  the  bath ;  the  mouth  of  the  infant  is 
carefully  washed  with  a  piece  of  absorbent  cotton  wrapped  around  a 
toothpick  and  moistened  with  boric  acid  solution.  'No  force  should 
be  used,  and  no  hard  pressure  exerted  against  the  roof  of  the  mouth 
especially,  as  in  this  way  ulceration  may  result. 

In  order  to  avoid  the  introduction  of  sprue  into  the  mouth,  the 
bottle  nipples  should  be  boiled  once  a  day  for  ten  minutes  in  a  soda 
solution,  and  cleansed  carefully  with  hot  water  after  each  nursing. 
In  the  intervals  of  nursing  the  rubber  nipples  are  best  kept  either  in 
a  glass-covered  jar  or  in  a  piece  of  absorbent  gauze.  It  is  well  not  to 
keep  them  in  a  solution  of  boric  acid,  as  this  is  apt  to  become 
contaminated. 

It  has  been  maintained  by  some  that  washing  the  mouth  of  the 
infant  nursing  at  the  breast  is  prophylactic  against  infection  of  the 
breast  by  bacteria  of  the  infant's  mouth.  Aside  from  the  fact  that 
the  bacteria  which  exist  in  the  mouth  of  the  newborn  and  young 
infant,  before  the  eruption  of  teeth,  are  not  pathogenic,  no  one  has 
proved  that  they  are  capable  of  causing  breast  abscess.  Epstein 
has  shown  conclusively  that  washing  the  mouth  of  infants  is  pro- 
ductive of  infectious  ulcerations  of  the  mucous  membrane  of  the 
buccal  cavity,  as  well  as  the  means  by  which  extraneous  infections, 
such  as  gonorrhoea  and  sprue  are  engrafted  on  the  mucous  membrane. 

In  the  newborn  the  production  of  buccal  ulcerations  as  a  result 
of  a  too  diligent  toilet  of  the  mouth  is  not  without  great  danger. 
It  has  been  long  acknowledged  that  bacteria  may  gain  access  to  the 
circulation  through  these  ulcerations  and  thus  cause  general  sepsis. 

THE  ADMINISTRATION  OF  DRUGS  AND  OTHER  METHODS  OF 

THERAPY. 

Medicinal  Treatment. — CUiildren  should  receive  drugs  in  an 
agreeable  form,  although  some  may  take  nauseous  drugs  with  ap- 
parent indifference.  Bulky  mixtures  or  drugs  which  are  apt  to  upset 
the  stomach  should  not  be  prescribed.  The  author  has  seen  a  severe 
enterocolitis  set  up  by  a  cough  mixture  containing  antimony.  Drugs 
should  not  be  administered  in  pill  form  to  infants  or  children.  Tab- 
lets are  a  ready  means  of  administering  certain  drugs.  They  can  be 
crushed  and  given  in  a  teaspoonful  of  some  indifferent  fluid.  Powders 
are  also  easily  taken.     They  are  put  in  a  spoon,  some  fluid  added  to 


TEE  ADMINISTRATION  OF  DEVGS.  63 

form  a  mixture,  which  is  then  administered.  Quinine  is  given  either 
in  syrup  of  yerba  santa  or  in  chocolate  powder  and  water;  or  the 
child  is  given  a  piece  of  chocolate  to  eat,  and  the  quinine  is  then  ad- 
ministered. A  child  should  never  be  forced  to  take  a  medicine. 
Much  harm  is  done  in  this  way. 

Certain  drugs,  such  as  opium  in  the  form  of  the  simple  tincture 
or  morphine,  should  be  given  with  great  caution  to  children  under  the 
age  of  two  years.  Atropine,  of  late  advocated  in  cholera  infantum, 
should  be  given  cautiously  to  infants  and  young  children.  They  bear 
this  drug  badly.  Jaboraudi  is  badly  borne,  as  is  also  apomorphine. 
Camphor  is  a  very  good  cardiac  stimulant.  It  is  useful  in  collapse, 
but  must  be  given  cautiously  in  cases  in  which  there  is  diarrhoea.  In 
the  latter  disease  the  camphor  is  apt  to  irritate  the  stomach  and  gut. 
The  coal-tar  series,  such  as  antipyrin,  antifebrin,  and  phenacetin, 
are  powerful  depressants.  In  those  cases  of  fever  in  which  it  is  not 
possible  to  give  baths  to  lower  the  temperature  we  are  sometimes 
forced  to  administer  these  drugs.  It  is  then  well  to  combine  them 
with  small  doses  of  caffeine. 

If  a  child  or  an  infant  refuses  to  take  a  drug,  it  may  be  put 
in  a  teaspoon,  the  spoon  held  horizontally  to  the  lips,  and  when  the 
mouth  is  opened  the  spoon  carried  far  back  into  the  mouth  and 
tilted.  The  spoon  is  held  in  the  mouth  until  the  act  of  swallowing, 
which  must  inevitably  take  place,  is  completed ;  the  spoon  is  then 
withdrawn.  If  this  manoeuvre  is  thus  carried  out,  the  fluid  will  not 
be  rejected.  Holding  the  nostril  closed,  and  thus  forcing  the  child  to 
open  the  mouth,  is  bad  practice.  Patience  and  suasion  can  accom- 
plish as  much  in  most  cases. 

Digitalis  is  not  given  continuously,  but  is  administered  for  two 
or  three  days,  and  when  the  pulse  begins  to  show  signs  of  lessened 
frequency  its  administration  is  susj)ended.  iVlcohol  is  well  borne  by 
children.  I  do  not  hesitate  to  administer  it  in  cases  of  nephritis  if 
the  heart  is  weak.  In  the  gastro-enteritis  of  nurslings  the  stomach 
is  intolerant  of  alcohol.  It  should  not  be  given  except  in  very  severe 
cases  accompanied  by  great  prostration,  as  the  vomiting  is  apt  to 
be  aggravated. 

Antipyretics. — Much  has  been  written  concerning  antipyresis  and 
antipyretics  in  the  treatment  of  the  diseases  of  infancy  and  child- 
hood. The  young  practitioner  can  feel  assured  that  high  tempera- 
tures are  well  borne  by  infants  and  children.  A  temperature  of 
106.5°  F.  (41.3°  C.)  in  an  adult,  although  of  short  duration,  would 
cause  great  alarm,  and  rightly  so.  On  the  other  hand,  such  a  tem- 
perature in  an  infant  or  child  does  not  necessarily  threaten  life,  nor 
is  it  incompatible  with  recovery.  A  convulsion  is  in  some  children 
the  direct  result  of  a  rise,  of  temperature.     Such  a  convulsion  will  not 


64  INFANCY  AND  CHILDHOOD. 

necessarily  lead  to  others  nor  to  epilepsy.  The  heart  and  kidneys 
bear  long-continued  high  temperature  well  in  comparison  with  those 
of  the  adult.  The  most  trivial  causes  will  cause  a  rise  of  a  degree 
or  two  in  the  temperature  of  an  infant  or  a  child.  Taking  all  these 
idiosyncrasies  into  consideration,  it  may  easily  be  understood  by 
the  student  and  practitioner  why  it  is  essential  that  methods  of 
therapy  should  be  modified  before  they  can  be  applied  to  infants 
and  children.  A  reduction  of  temperature  from  104°  to  102°  F., 
even  if  it  can  be  accomplished  by  a  coal-tar  derivative,  does  not 
cure  the  patient.  Some  diseases,  such  as  measles,  scarlet  fever, 
pneumonia,  and  a  number  of  others,  run  a  course  of  high  and  low 
temperatures  extending  over  a  certain  space  of  time.  If  an  infant 
or  child  is  attacked  with  convulsions  following  every  acute  rise  of 
temperature,  the  parents  should  be  warned  of  this  fact.  In  these 
cases,  as  soon  as  a  rise  of  temperature  is  noted,  it  should  be  com- 
bated by  every  means  in  our  power.  Reduction  of  temperature  in 
such  children  at  the  outset  of  a  disease  is  of  the  highest  utility. 
It  saves  the  nervous  system  from  the  shock  of  a  convulsion.  Hydro- 
therapy is,  in  such  cases,  the  safest  and  most  satisfactory  antipyretic 
measure  at  our  disposal. 

Dosage. — The  dosage  of  drugs  for  infants  and  children  has  re- 
ceived much  attention.  In  practice  we  judge  more  by  the  action  of  a 
remedy  than  the  quantity  administered.  The  initial  dose  should  be 
small.  Infants  under  a  year  receive  /4oth  of  the  adult  dose,  and  at  the 
age  of  one  year  %oth  of  the  adult  dose  is  safe.  At  the  fifth  year  /^th, 
and  at  the  tenth  year  %  the  adult  dose  is  the  rule.  These  figures  are 
not  absolute.  ISTitroglycerin  if  given  in  doses  of  less  than  /45oth  of 
a  grain  has  scarcely  any  effect  on  children  five  years  of  age.  On  the 
other  hand,  strychnine  may  be  safely  given  in  quantities  of  /^snth  of 
a  grain  to  infants,  and  Msoth  of  a  grain  to  children  two  to  three  years 
of  age.  It  will  be  seen  that  if  the  hard-and-fast  rule  of  division  of 
doses  according  to  age  were  followed,  these  drugs  would  necessarily 
be  given  in  much  smaller  dose,  and  their  action  would  be  correspond- 
ingly inefficient. 

Hypodermic  Administration. — Hypodermic  administration  of  drugs 
to  infants  and  children  presents  nothing  peculiar,  as  compared  with 
the  same  method  applied  to  adults. 

Hydrotherapy. — The  practice  of  hydrotherapy  as  applied  to  the 
adult  must  be  somewhat  modified  before  it  can  be  carried  out  with  the 
infant  or  the  child.  The  reason  for  this  is  that  the  infant  or  child 
does  not  react  so  readily  and  cannot  bear  sudden  changes  of  tempera- 
ture so  well  as  the  adult. 

The  Sponge  Bath. — A  rubber  sheet  is  placed  on  the  crib,  and  over 
this  one  layer  of  a  small  blanket;  the  patient  is  then  placed  nude 


TEE  ADMINISTEATION  OF  DEUGS.  65 

on  this  blanket  and  covered  with  another  blanket.  There  is  thus  no 
undue  exposure.  A  small  basin  of  water  at  80°  to  85°  F.,  with  a 
dash  of  alcohol,  is  now  brought  alongside  of  the  crib.  With  a  small 
sponge  or  piece  of  soft  folded  linen  the  parts  of  the  patient  are 
sponged;  first  one  arm,  then  the  other,  then  the  trunk,  and  finally 
the  lower  extremities.  As  each  part  is  exposed,  the  rest  of  the  body 
is  kept  covered.  This  procedure  is  repeated  until  the  body  has  been 
sponged  for  five  or  ten  minutes.  This  method  of  hydrotherapy  is 
especially  suitable  in  acute  rises  of  temperature  of  short  duration 
and  in  mild  cases  of  continued  fever  in  which  the  temj)erature  does 
not  rise  high. 

Cold  Chest  Compress.^ — Three  layers  of  linen  are  cut  so  that  they 
will  envelop  the  trunk  from  the  clavicles  to  the  umbilicus.  The  gen- 
eral shape  should  be  that  of  a  shirt  deprived  of  arms  and  open  at 
the  sides.  On  the  outside  of  this  linen  compress  there  should  be  a 
compress  of  Shaker  flannel  cut  in  a  similar  manner.  The  compress 
of  linen  is  moistened  with  water  at  80°  to  85°  F.  With  robust 
children  the  water  may  be  70°  F.  The  compress  is  wrung  out  and 
applied  so  that  the  neck,  shoulders,  and  chest  are  covered  as  with  a 
shirt.  The  flannel  is  now  applied  to  the  outside.  The  compress  is 
moistened  every  hour  with  water  at  70°  to  85°  F.  and  re-covered  with 
the  flannel. 

Cold  Pack. — The  cold  pack  is  not  so  useful  in  the  treatment  of  the 
febrile  conditions  of  childhood.  The  method  is  similar  to  that  fol- 
lowed with  the  adult,  with  the  exception  that  the  sheet  is  moistened 
with  water  at  80°  to  85°  F.  In  other  cases  the  patient,  after  being 
wrapped  in  such  a  sheet,  is  rubbed  by  the  attendant  with  ice  on  the 
outside  of  the  sheet. 

The  Full  Bath. — The  full  bath,  as  advocated  by  Brand,  is  seldom 
carried  out  in  the  treatment  of  children.  Children  struggle  against 
the  bath,  and  if  the  temperature  is  too  low,  they  become  so  depressed 
that  it  is  difficult  to  rouse  them.  I  therefore  place  children  with 
typhoid  fever,  pneumonia,  or  scarlet  fever  in  a  bath  at  100°  to  105° 
F.,  and  lower  the  temperature  to  80°  or  85°  F.,  applying  friction  to 
the  body  constantly.  After  five  or  ten  minutes  the  patients  are  taken 
out  of  the  bath  and  rubbed  dry.  Warm-water  bottles  are  applied  to 
the  hands  and  feet. 

In  conditions  of  delirium  and  coma  with  a  high  temperature,  in 
which  the  heart  is  weak,  I  have  given  baths  at  a  temperature  of 
105^  to  108°  F.  The  cases  in  which  these  baths  are  indicated  are 
those  in  which  any  application  of  cold  water  causes  cyanosis  and 
collapse.  I  have  seen  infants  suffering  from  bronchopneumonia, 
with  high  temperatures,  in  a  condition  resembling  a  rigor  after  a 

5 


66  INFANCY  AND  CHILDHOOD. 

bath  at  85°  F.  With  these  infants  the  warm  bath  acts  as  a  cardiac 
stimulant  and  is  a  sedative  to  the  nervous  system. 

Hypodermoclysis. — Hypodermoclysis  is  the  introduction  into  the 
subcutaneons  tissue  of  either  a  0.6  percent,  salt  solution  or  the  normal 
salt  solution  of  Cantani  (sodium  chloride,  4  parts;  sodium  carbo- 
nate, 3  j^arts;  water,  1000  parts).  It  is  indicated  in  infants  suffer- 
ing from  cholera  infantum  and  in  other  exhausting  states.  ]\[onti, 
who  was  the  first  to  apply  this  mode  of  therapj^  to  the  infant,  injects 
100  to  200  c.c.  at  a  time.  Epstein  showed  that  smaller  quantities — 
10  to  40  c.c. — are  more  beneficial  and  more  quickly  absorbed.  Ex- 
perience teaches  that  large  quantities  of  fluid  injected  subcutaneously 
cause  extensive  blood  extravasations  in  exhausted  infants  and  much 
subsequent  pain.  The  solutions  used  should  be  freshly  prepared  and 
sterilized.  Welch  has  reported  cases  of  infection  with  Bacillus 
aerogenes  capsulatus  following  hypodermoclysis.  I  have  had  one 
case,  although  every  precaution  was  taken  to  avoid  infection. 

A  large  antitoxin  syringe,  holding  30  c.c,  is  used.  It  should  be 
carefully  sterilized.  Or  a  fountain  syringe  may  be  employed,  and 
the  solution  introduced  through  a  needle  attached  to  the  tubing  of  the 
syringe. 

From  20  to  30  c.c.  of  the  solution  is  injected  two  or  three  times 
daily  into  the  subcutaneous  tissue  of  the  lumbar  region  or  abdomen. 
Monti  injects  into  the  subcutaneous  tissue  of  the  abdomen.  Mas- 
sage should  not  be  performed  after  injection,  as  it  is  very  painful 
and  causes  hemorrhages.  The  puncture  wound  is  covered  with  a 
piece  of  sterile  gauze.  The  main  point  is  to  inject  small  quantities 
of  the  solution  at  intervals  of  from  four  to  six  hours,  and  watch  the 
effect.  The  action  is  that  of  a  stimulant  to  the  heart  and  the 
processes  of  resorption.  Epstein  showed  that  within  a  few  hours 
after  injection  of  salt  solution  the  proportion  of  haemoglobin  and 
red  blood-cells  were  reduced.  As  salt  solution  has  a  dissolving  effect 
on  the  red  blood-cells,  the  injection  of  large  quantities  of  the  solu- 
tion may  be  harmful. 

SyTinging  of  the  Nose Instruments. — The  best  form  of  syringe 

for  this  purpose  is  an  olive-tipped  glass  syringe.  Some  forms  are 
made  with  a  soft-rubber  tip.  The  tip  should  be  blunt,  lest  the  nares 
be  injured  (Fig.  7). 

Fig.  7. 


,  Nasal  syringe.     Correct  shape. 

The  solution  used  is  generally  a  normal  salt  solution. 
Method, — The  patient  is  wrapped  in  a  sheet  or  blanket,  and  held 
iij  the  lap  of  a  nurse,  who  holds  a  pus  basin  beneath  the  chin.     The 


TRE  ADMINISTBATION  OF  DBUGS. 


67 


operator  stands  behind  the  patient.  The  syringe  is  held  horizontally 
to  the  floor  of  the  nares  and  the  solution  slowly  injected  into  the 
nostril  (Fig.  8).  If  successfully  performed,  the  procedure  results 
in  the  solution's  coming  out  of  the  other  nostril.  There  is  no 
danger  in  the  manoeuvre  if  carefully  carried  out.  If  the  infant  is 
too  weak,  the  nares  may  be  syringed  with  the  patient  in  bed  in  the 


FiG.  8. 


^^eyief^ 


Method  of  syringing  the  nose  in  the  upright  posture. 


recumbent  posture.  The  nurse  stands  at  one  side,  and  the  head  is 
placed  on  the  side,  the  pus  basin  beneath  the  nose,  as  shown  in 
Fig.  9.  A  rubber  fountain-syringe  may  be  used  in  the  same  manner. 
Here  also  the  position  of  the  syringe  is  horizontal  to  the  floor  of 
the  nares.  The  syringe  should  be  thoroughly  boiled  before  and 
after  using.  An  old  syringe  should  never  be  used,  no  matter  how 
carefully  it  has  been  sterilized. 


68 


INFANCY  AND  CHILDHOOD. 


Vapor  Spray ;  Calomel  Inhalations  in  Acute  Laryngeal  Disease. — 

With  infants  and  children  the  spray  is  not  so  useful  an  agent  as 
steam  vapor  impregnated  with  balsams  or  turpentine,  and  combined 
at  times  with  inhalations  of  the  fumes  of  sublimed  calomel.  The 
spray  cannot,  as  a  rule,  be  used  locally  except  with  the  most  tractable 
children.    With  infants  its  use  is  not  feasible. 

The  vapor  of  steam  impregnated  with  balsams  or  turpentine  is 
very  useful  in  all  forms  of  acute  laryngitis  in  which  there  is  no 
bronchitis.  I  dispense  with  steam  vapor  if  bronchitis  is  present. 
The  mode  of  application  in  catarrhal  or  membranous  croup  is  as 
follows :  The  crib  is  covered  with  a  sheet  suspended  from  four 
upright  poles  fastened  to  the  corners  of  the  crib.  A  tent  is  thus 
formed.     The  croup  kettle  is  placed  at  one  side  of  the  crib,  in  such  a 

Fig.  9. 


Method  of  syringing  the  nose  in  the  recumbent  posture. 


manner  that  the  steam  vapor  escapes  into  the  improvised  tent.  The 
vapor  is  medicated  by  placing  in  the  kettle  a  teaspoonful  of  turpentine 
or  thymol.  This  will  be  readily  vaporized.  ISTo  special  apparatus 
has  any  advantage  over  the  ordinary  croup  kettle.  If  calomel  sub- 
limations are  to  be  given,  they  should  be  combined  with  the  steam 
vapor.  Ten  grains  of  calomel  are  placed  in  a  spoon  held  over  an 
ordinary  candle,  and  the  fumes  led  under  the  tent,  the  air  of  which 
is  impregnated  with  steam  vapor.  The  special  devices  sold  for  the 
sublimation  of  calomel  may  be  used,  but  possess  no  advantage  over  the 
method  described  above  (Fig.  10).  Calomel  sublimations  are  ex- 
ceedingly irritating,  but  they  relieve  the  patient  very  promptly.  They 
may  be  continued  for  forty-eight  hours  at  intervals  of  two  hours, 
without  fear  of  salivation. 


TEE  ADMINISTBATION  OF  DKUGS. 


69 


Stomach  Washing. — One  of  the  most  valuable  additions  to  our 
therapeutic  armament  within  recent  years  is  stomach  washing  in  case 
of  the  nursing  infant.  ISTo  improvement  has  been  made  upon  the 
method  as  first  proposed  by  Epstein.  The  cases  in  which  it  is  indi- 
cated are  mentioned  in  another  part  of  this  work.  The  procedure 
is  easiest  of  application  to  nurslings  in  whom  there  are  no  teeth  or  in 
whom  very  few  teeth  have  erupted.  With  these  subjects  there  is  no 
danger  of  the  catheter's  being  bitten,  and  there  is  no  necessity  of  using 
a  gag.  With  older  children,  however,  a  gag  must  be  used  when 
stomach  washing  is  attempted.  The  Denhardt  gag  of  the  O'Dwyer 
set  of  intubating  instruments  is  most  suitable  for  this  purpose. 

Fig.  10. 


Sublimer  for  calomel  inhalation. 


Indications. — Washing  out  the  stomach  is  principally  indicated 
in  the  acute  gastro-enteritis  of  the  summer  months.  It  is  not  bottle- 
fed  infants  alone  that  are  attacked,  but  even  breast-fed  infants  may 
be  thus  affected.  The  winter  months  also  furnish  their  quota  of 
these  cases.  One  vomiting  spell,  as  it  is  called,  does  not  require 
attention.  If,  however,  on  suspension  of  the  bottle  or  breast,  vomit- 
ing continues  and  becomes  uncontrollable,  we  proceed  to  stomach 
irrigation.  Another  indication  is  the  so-called  chronic  dyspeptic 
vomiting.  Those  who  advocate  this  method  of  treatment  in  these 
cases  forget  that,  above  all,  the  food  is  at  fault,  and  must  be  regulated 
and  modified.     I  do  not  favor  washing  the  stomach  in  these  cases. 

One  washing  is,  as  a  rule,  sufficient.  I  have  rarely  had  to 
repeat  it.  If  vomiting  persists  after  the  first  washing,  it  is  well  to 
look  for  other  conditions  than  gastro-enteritis,  such  as  intussuscep- 
tion, as  the  cause  of  the  vomiting.     Stomach  washing  is  also  a  favorite 


70 


INFANCY  AND  CHILDHOOD. 


mode  of  treatment  in  cases  of  persistent  vomiting  due  to  spasm  or 
stenosis  of  the  pylorus. 

Acute  drug  poisoning  or  ingestion  of  any  irritating  fluid  is  quickly 
relieved  by  stomach  washing.  I  have  washed  out  many  children 
who  had  been  given  an  overdose  of  paregoric,  or  who  had  taken 
Paris  green,  turpentine,  or  other  drug.  If,  as  sometimes  happens,  a 
child  accidentally  swallows  a  caustic  alkali,  we  should  not  introduce 
the  tube  into  the  oesophagus  or  stomach. 

Method.' — A  four-ounce  funnel,  a  piece  of  rubber  tubing  two  and 
a  half  feet  long,  and  a  ISTo.  14  rubber  catheter  are  the  instruments 

Fig.  11. 


Apparatus  for  washing  out  the  stomach. 


necessary.  The  rubber  tubing  is  attached  to  the  funnel,  and  by 
means  of  a  piece  of  glass  tubing  to  the  catheter,  as  in  Fig.  11. 
About  a  quart  of  normal  saline  solution  is  needed.  The  temperature 
of  the  water  should  be  at  least  100°  F.  The  operator  needs  one 
assistant. 

The  infant  is  completely  undressed,  and  is  then  wrapped  in  a 
blanket,  the  diaper  having  first  been  applied.  The  hands  are  tucked 
in  with  safety-pins.  The  infant  having  been  laid  recumbent  on  a 
table,  the  operator,  standing  on  the  right,  introduces  his  left  index 


< 


TRE  ADMINISTRATION  OF  DBUGS.  71 

finger  into  the  mouth  and  depresses  the  tongue  (Plate  I.)-  The 
catheter,  moistened  with  water,  is  now  introduced  and  passed  back- 
ward. With  gentle  urging  the  catheter  passes  easily  into  the  oesopha- 
gus. There  is  no  likelihood  of  the  catheter's  passing  into  the  larynx 
and  trachea.  About  six  inches  of  the  catheter  are  introduced.  The 
funnel  is  depressed  and  the  stomach  contents  are  first  allowed  to 
flow  out.  The  funnel  is  then  raised  about  two  feet  above  the  patient, 
and  the  assistant  slowly  pours  the  saline  solution  into  the  funnel,  the 
fluid  flowing  into  the  stomach.  Before  the  funnel  is  completely 
emptied,  it  is  lowered  and  the  stomach  contents  siphoned  out.  This 
operation  is  repeated  several  times,  until  the  water  returns  quite 
clear.  If  during  the  stomach  washing  the  fluid  should  be  ejected 
from  the  stomach  in  the  act  of  vomiting,  it  will  easily  flow  out  of  the 
mouth  if  the  infant  is  recumbent.  There  is  not  the  slightest  danger 
of  aspiration  of  the  fluid  into  the  trachea.  I  think  the  recumbent 
position  is  superior  to  the  sitting  posture  advocated  by  some  clinicians. 
A  young  infant  is  unable  to  sit  up  of  its  ovni  accord. 

The  introduction  of  the  tube  is  not  so  easy  for  the  infant  in  the 
sitting  posture  as  in  the  recumbent  position.  The  tube  being  intro- 
duced, the  stomach  contents  sometimes  refuse  to  flow  out  because 
mucus  and  food  particles  obstruct  the  lumen  of  the  catheter.  In 
such  cases  the  catheter  is  withdrawn,  and  washed  out.  The  catheter 
is  then  pinched  with  the  fingers  in  such  a  manner  that  some  of  the 
water  or  washing  solution  remains  in  the  catheter.  It  is  then  intro- 
duced into  the  stomach.  In  this  way  the  catheter,  being  filled  with 
fluid,  mucus  and  food  cannot  obstruct  the  lumen  of  the  tube  before 
siphonage  is  begun.  Fluid  can  then  readily  be  introduced  into  the 
stomach.  These  difficulties  occur  in  cases  in  which  there  is  a  large 
amount  of  mucus  in  the  stomach.  The  finger  should  always  be 
retained  in  the  mouth.  By  grasping  the  catheter  with  the  thumb 
and  index  finger  of  the  right  hand,  prying  open  the  mouth  at  the 
same  time,  we  prevent  pressure  on  the  catheter  during  the  washing. 
If  the  infant  has  upper  and  lower  incisors,  the  catheter  must  be  held 
at  one  side  of  the  mouth  and  the  mouth  kept  open  by  means  of  the 
index  finger  held  in  the  angle  of  the  mouth.  The  method  described 
above  has  been  followed  by  me  for  years.  I  have  never  had  an 
accident. 

Gavage. — Gavage  is  a  method  of  forced  feeding  by  means  of  the 
stomach-tube.  I  have  practised  this  method  of  feeding  infants  and 
older  children  suffering  from  pneumonia  or  typhoid  fever,  who  were 
delirious  or  unconscious.  It  is  also  a  method  which  has  been  pro- 
posed in  cases  of  uncontrollable  vomiting  and  I  have  utilized  it  in 
patients  suffering  with  spasm  of  the  pylorus. 

The  method  of  procedure  is  similar  to  that  used  in  stomach  wash- 


72  ■  INFANCY  AND  CHILDHOOD. 

ing.  It  is  best  uot  to  introduce  the  catheter  through  the  nose,  but 
to  keep  the  mouth  open  with  some  device.  If  the  catheter  is  passed 
through  the  nose,  no  food  shoukl  be  introduced  into  the  funnel  until 
we  are  sure  the  feeding-tube  is  in  the  stomach.  With  older  children 
a  tube  passed  through  the  nose  may  pass  into  the  larynx.  If  it 
has  done  so,  a  hissing  sound  will  be  heard.  Aphonia  will  also  be 
present.  In  infants  and  young  children  the  glottis  is  small,  and  a 
full-sized  catheter  will  not  readily  pass  into  it.  After  the  tube  is 
in  the  stomach  the  prescribed  amount  of  liquid  food  is  introduced 
and  the  tube  rapidly  withdraAvn.  The  feeding  may  be  repeated  every 
four  to  six  hours. 

Rectal  Enemata;  Irrigation;  Enteroclysis. — The  bulk  of  an  or- 
dinary enema,  introduced  in  order  to  empty  the  bowel,  should  be 
from  2  to  4  ounces.  A  Davidson's  bulb  syringe  should  not  be  used. 
A  jSTo.  16  or  No.  18  catheter  is  attached  to  the  nozzle  of  an  ordinary 
four-ounce  hard-rubber  syringe.  The  infant  or  child  is  placed  on  its 
side,  with  a  rubber  sheet  under  the  buttock.  The  tip  of  the  catheter 
is  oiled  and  passed  well  within  the  anal  ring.  The  catheter  is  then 
attached  to  the  nozzle  of  the  syringe  containing  the  fluid  to  be  injected, 
and  the  fluid  is  gently  thrown  into  the  rectum.  An  enema  commonly 
used  is  soap-water,  with  the  addition  of  a  tablespoonful  of  castor  oil 
or  glycerin. 

The  high  rectal  enema,  irrigation,  or  enteroclysis,  is  given  in 
all  forms  of  summer  diarrhoea,  dysentery,  and  in  typhoid  fever.  It 
is  also  indicated  in  cases  in  which  there  are  symptoms  of  collapse,  in 
exhausting  diseases,  in  nephritis,  and  after  operations.  It  was  for- 
merly a  method  employed  to  reduce  an  intussusception  in  its  early 
stages  but  is  not  now  in  vogue.  In  diarrhcea,  the  object  of  the  high 
rectal  enema  is  twofold — to  clear  out  the  faces  from  the  lower 
bowel,  and  to  supply  fluid  to  the  depleted  circulating  blood,  thereby 
stimulating  the  heart.  The  latter  is  the  main  object  in  practising 
enteroclysis  in  states  of  exhaustion  and  after  operations.  In  sup- 
pression of  urine  we  aim  to  supply  fluid  to  the  kidneys  and  stimu- 
late the  circulation.  According  to  Kemp,  the  high  rectal  enema 
is  one  of  our  most  useful  diuretics. 

The  solution  employed  is  the  Cantani  saline  solution  (sodium 
carbonate,  3.0;  sodium  chloride,  4.0;  water,  1000).  At  least  a 
quart  is  injected.  The  temperature  of  the  solution  for  simple  wash- 
ing of  the  gut,  as  in  diarrhoea,  should  be  that  of  the  body.  In 
nephritis  or  colkpse  the  temperature  should  be  at  least  108°  to 
110°  F.  (42.2°  to  43.3°  C). 

The  instrument  employed  may  be  a  bag  fountain  syringe,  of  a 
quart  capacity,  to  which  is  attached  a  small  calibre  soft-rubber 
rectal  tube  or  a  catheter,  or  the  rubber  tubing  and  catheter  may  be 
attached  to  a  six-ouuco  2;lass  funnel. 


^     .<*<- 


03 

3 


TBE  ADMIN  I  ST  EAT  I  ON  OF  DBUGS.  73 

The  patient  is  completely  undressed  and  laid  on  a  table  on  the 
side,  with  the  knees  flexed  and  the  buttocks  near  the  edge.  A 
rubber  sheet  placed  underneath  the  buttocks  leads  into  a  pail,  so  that 
the  returning  water  will  drain  off  (Plate  II.)-  Tlie  buttocks  are 
placed  slightly  higher  than  the  trunk.  The  catheter  or  rectal  tube 
is  oiled  and  introduced  two  or  three  inches  into  the  rectum,  the  water 
allowed  to  flow,  and  the  tube  passed  higher  up.  Sometimes  there  is 
an  obstruction  to  the  passage  of  the  tube,  and  then  it  is  necessary  to 
introduce  the  finger  cautiously  into  the  rectum  alongside  of  the  tube 
and  guide  it  past  the  upper  sigmoid  ring.  The  tube  may  thus  be 
passed  from  six  to  eight  inches  into  the  gut.  It  is  seldom  necessary 
to  introduce  it  higher,  as  the  water  will  find  its  way  into  the  colon. 
About  a  pint  or  more  of  water  is  then  allowed  to  flow  into  the  gut. 
It  is  not  necessary  to  compress  the  anus  around  the  catheter  to 
prevent  the  escape  of  the  fluid.  Some  of  the  fluid  may  escape  along- 
side the  catheter.  In  some  forms  of  exhausting  diarrhoea  a  portion  of 
the  saline  solution  should  be  left  in  the  gut  after  it  has  been  well 
irrigated,  in  order  to  stimulate  the  heart  and  supply  fluid  to  the 
circulation.  Two  irrigations  may  be  necessary  in  the  twenty-four 
hours,  rarely  more.  In  typhoid  fever  one  low  irrigation  is  given 
daily.  In  some  subjects,  if  the  irrigations  are  continued  too  long, 
hypersemia  of  the  mucous  membrane  results.  Clinically,  this  is 
manifested  by  a  continuance  or  increase  of  mucus  in  the  washings, 
and  also  by  the  occasional  presence  of  blood.  In  such  cases  the 
enemata  should  be  suspended. 

In  nephritis  complicating  scarlet  fever,  rectal  irrigation  is  one 
of  the  recognized  methods  of  stimulating  the  secretion  of  the  kidney, 
which  result,  according  to  Kemp,  begins  twenty  minutes  after  the 
fluid  is  introduced  into  the  gut.  With  adults  the  Kernp  tube  is 
used,  but  with  children,  who  are  difiicult  to  keep  quiet,  continuous 
irrigation  is  not  feasible.  In  these  cases  high  enteroclysis  is  given 
in  the  ordinary  manner,  as  much  of  the  solution  as  possible  being 
retained  in  the  rectum.  This  procedure  may  be  repeated  two  or 
three  times  daily.  In  giving  ordinary  enteroclysis  the  bag  of  the 
fountain  syringe  or  funnel  should  not  be  held  more  than  three  feet 
above  the  body  of  the  patient,  lest  the  pressure  be  too  great.  About  a 
pint  of  fluid  at  a  time  is  allowed  to  flow  into  the  gut ;  the  catheter  is 
then  disconnected,  and  the  contents  of  the  gut  allowed  to  flow  out. 
A  stimulating  enema  is  given  after  an  operation,  or  when  symp- 
toms of  collapse  appear  in  any  acute  illness.  Only  small  quantities 
of  solution  are  allowed  to  flow  into  the  rectum.  A  formula  in  use 
in  my  wards  is  the  following: 


74  INFANCY  AND  CHILDEOOD. 

Whiskey 3j. 

Caffeine gr.  *. 

Tint,  digital gtt.  ij. 

Sol.  sodium  chloride  (0.6  per  cent.) ^J- 

Temperature,  102°-10.5°  F. 

Xutritive  enemata  are  used  when  for  any  reason,  such  as  uncon- 
trollable vomiting,  the  stomach  must  be  given  complete  rest.  Soma- 
tose  solution,  of  one  teaspoonful  of  somatose  dissolved  in  eight  ounces 
of  cold  water,  is  given  lukewarm  Sij  at  a  time,  every  four  hours. 
Or,  ext.  pancreatis,  gr.  v ;  sod.  bicarb.,  gr.  ij ;  water  §iv ;  milk,  oxvj ; 
with  or  without  the  addition  of  an  egg.  Give  Bij  or  §iij.  These 
enemata  should  be  given  slowly  and  high  up,  and  in  small  quantities 
at  a  time. 

Tor  constipation  in  cases  in  which  faeces  have  become  impacted 
and  are  in  the  form  of  hard  scybala  the  following  is  excellent : 

Olive  oil 3ij. 

Glycerin 5j- 

This  should  be  injected  to  be  followed  after  a  few  hours  by  an  ordi- 
nary enema  of  soap-water. 

In  cases  of  cardiac  disease  with  uncontrollable  vomiting,  digitalis 
is  administered  with  excellent  results  by  the  rectum.  The  requisite 
dose  of  infusion  is  placed  in  simple  water  up  to  the  bulk  of  two 
ounces  and  is  then  introduced  high  in  the  rectum.  This  may  be 
repeated  three  times  daily  for  days. 

Lumbar  Puncture. — Lumbar  puncture  was  first  practised  by 
Quincke.  It  is  to-day  one  of  the  most  useful  adjuncts  to  the  methods 
of  diagnosis  in  acute  and  chronic  forms  of  cerebral  and  spinal  dis- 
ease. Its  future  usefulness  as  a  therapeutic  measure  is  not  clearly 
established,  but  will  probably  lie  in  relieving  symptoms  due  to  pres- 
sure, removing  the  excess  of  inflammatory  exudate  in  the  various 
forms  of  meningitis,  and  introducing  sera  and  curative  agents  into 
the  subarachnoid  space. 

The  Normal  Cere'brospinal  Fluid. — Normal  cerebrospinal  fluid  is  a 
clear  colorless  fluid  having  a  slightly  alkaline  or  neutral  reaction.  Its 
specific  gravity  varies  from  1007  to  1009.  It  contains  from  0.05 
to  0.1  per  cent,  of  albumin  (Quincke,  Rieken,  Pfaundler),  and  be- 
cause of  the  presence  of  sugar  (0.05  per  cent.)  has  a  slightly  re- 
ducing action  on  copper.  It  does  not  coagulate  spontaneously.  If 
centrifiiged,  a  microscopic  sediment  of  a  few  endothelial  cells  and 
small  mononuclear  cells  and  lymphocytes  may  be  obtained.  The 
cerebrospinal  fluid  is  normally  under  a  pressure  of  from  5  to  20 
millimetres  of  mercury  or  40  to  150  mm.  of  water.  The  pressure 
in  infants  is  lower  than  that  in  children.  The  causes  of  the  variations 
of  pressure  and  the  nature  of  the  conditions  under  which  they  occur 


THE  ADMINISTBATION  OF  DEUGS.  75 

have  not  as  yet  been  determined.  Kespiration  causes  a  deviation  of 
fully  6  millimetres  of  mercury  in  the  manometer  column. 

Abnormal  Conditions. — The  cerebrospinal  fluid  will  in  pathological 
states  vary  in  respect  to  specific  gravity,  composition,  appearance, 
and  in  the  amount  of  sediment  contained.  The  pressure  in  the  sub- 
arachnoid and  cerebrospinal  spaces  v^^ill  also  vary  in  different  forms 
of  disease.  It  is  increased  in  inflammatory  states,  hydrocephalus, 
hemorrhage,  tumors  of  the  brain,  abscess,  acute  alcoholism,  eclampsia 
and  epilepsy. 

Specific  Gravity. — -The  specific  gravity  in  tuberculous  meningitis 
varies  from  1003  to  1011  (Lenhartz),  in  cerebrospinal  meningitis 
from  1005  to  1012  (Pfaundler). 

Gross  Appearances. — The  gross  appearances  of  the  fluid  obtained 
by  lumbar  puncture  may  be  changed  by  the  admixture  of  blood. 
Blood  may  come  from  the  puncture  wound  or  may  have  been  in  the 
canal  previous  to  puncture  as  a  result  of  a  hemorrhagic  pachymenin- 
gitis or  of  some  form  of  cerebrospinal  meningitis,  traumatism,  or 
apoplexy  with  rupture  into  the  ventricles.  The  wounding  of  veins 
either  in  the  tissues  or  in  the  cauda  equina  may  cause  an  admixture 
of  blood.  The  quantity  of  blood  may  be  just  sufficient  to  tinge  the 
fluid  or  the  blood  may  be  almost  pure.  It  is  not  possible  to  determine 
whether  the  admixture  of  blood  is  or  is  not  the  result  of  accidental 
puncture  of  a  vessel  unless,  as  in  pachymeningitis  or  traumatism, 
light  is  throv^i  on  the  matter  by  the  history  of  the  case  and  the 
presence  of  blood  on  repeated  puncture.  The  accidental  admixture 
of  blood  is  unfortunate,  since  it  obscures  the  microscopical  diagnosis. 
The  hemorrhage  into  the  spinal  canal  as  a  result  of  the  operation  of 
lumbar  puncture  is  never  alarming  or  of  serious  import. 

Tuberculous  Meningitis. — Tuberculous  meningitis  changes  the 
gross  appearance  of  the  fluid  obtained  by  lumbar  puncture.  The  fluid 
may  be  quite  clear,  exceptionally  cloudy,  opalescent,  or  in  rare  cases 
purulent.  As  a  rule,  however,  it  is  clear  in  the  early  stages  of  the 
disease  and  cloudy  in  the  later  period.  If  the  test-tube  is  held  in  a 
strong  light,  there  may  be  seen,  in  a  clear  or  cloudy  fluid,  myriads 
of  highly  refracting  particles  resembling  the  motes  in  a  sunbeam 
(Moser,  Bernheim,  Pfaundler).  The  appearance  is  quite  character- 
istic. It  was  first  explained  by  Lichtheim,  as  the  result  of  spontaneous 
coagulation.  If  a  test-tube  of  the  fluid  obtained  by  lumbar  puncture 
is  placed  in  the  upright  position  in  an  ice-box,  there  is  found  after 
twenty-four  hours,  a  fully  formed  cobweb-like,  funnel-shaped  coagu- 
lum,  beginning  a  little  below  the  surface  of  the  fluid  and  extending 
downward,  the  broader  part  of  the  funnel  being  above.  According 
to  Pfaundler,  this  coagulum  is  of  diagnostic  import.  I  have  relied 
on  its  appearance  in  fluid  which  was  not  contaminated  with  blood, 


76  INFANCY  AND  CHILDHOOD. 

and  found  it  of  great  value.  The  formation  of  the  coagulum  begins 
after  the  fluid  has  stood  for  two  hours,  and  is  fully  completed  by  the 
following  day.  It  is  usually  found  from  eight  to  twelve  days  before 
death. 

Suppurative  Meningitis. — In  this  form  of  meningitis,  the  fluid 
obtained  by  lumbar  puncture  is  purulent,  opalescent,  grayish-white, 
grayish-yellow,  or  brovmish  (hemorrhagic).  Exceptional  cases  give 
a  clear  fluid.  There  may  be  a  spontaneous  coagulum  resembling 
that  seen  in  tuberculous  meningitis. 

Epidemic  and  Sporadic  Cerebrospinal  Meningitis. — In  the  early 
stage  of  this  disease,  the  fluid  may  be  quite  clear  with  suspended 
microscopic  sediment.  It  may  also  be  cloudy  or  thick,  creamy  or 
bloody.  It  may  at  first  be  clear,  and  later  in  the  disease  become 
purulent  (Councilman). 

Chronic  Hydrocephalus. — This  gives  a  clear  fluid  with  no  sus- 
pended particles  visible  to  the  eye,  although  microscopically  there  may 
be  leucocytes.  Pfaundler  in  one  of  his  cases  obtained  a  fluid  which 
was  cloudy  because  of  the  admixture  of  leucocytes. 

Brain  Tumors. — Tumor  of  the  brain  gives  a  clear  fluid.  I  have 
had  such  cases. 

Sediment. — This  feature  will  be  fully  discussed  under  the  sec- 
tions devoted  to  tuberculous  meningitis  and  cerebrospinal  meningitis. 

Cytology. — The  cytology  of  the  fluid  in  an  acute  inflammation  is 
as  a  rule  polynuclear,  whereas  in  a  chronic  process  there  is  an  excess 
of  lymphocytes.  Organic  disease  of  the  meninges  such  as  syphilis 
will  cause  a  lymphocytosis.  Pathological  fluids  contain  small  mono- 
nuclear lymphocytes,  polynuclear  leucocytes,  transitional  forms,  large 
lymphocytes  (mononuclears)  with  basophile  granulations,  so-called 
plasma-cells,  and  finally  endothelial  cells.  In  addition  to  cellular 
elements  the  fluid  may  contain  bacteria.  These  will  be  discussed 
under  the  various  diseases.  Here  we  may  simply  mention  the  pres- 
ence of  the  pus  organisms.  Staphylococci,  Streptococci  of  various 
varieties,  Pneumococci,  Typhoid  bacilli,  Coli  bacilli,  Streptococcus 
mucosus,  Tetanus  bacillus.  Influenza  bacillus.  Bacterium  lactis 
aerogenes.  Bacterium  coli  immobilatus  and  capsulatus,  Saccharomyces 
glanders,  Meningococci,  and  Tubercle  bacilli.  In  fact  almost  any 
form  of  bacteria,  as  well  as  protozoan  bodies,  such  as  trypanosomes, 
have  been  found  in  the  cerebrospinal  fluid. 

Pressure. — The  pressure  under  which  the  cerebrospinal  fluid  is 
retained  in  the  subarachnoid  space  and  in  the  spinal  canal  is  in- 
creased in  the  various  forms  of  meningitis.  This  is  especially  true  of 
tuberculous  meningitis,  in  which  the  pressure  may  reach  110  mm.  of 
mercury.  In  this  disease  the  pressure  increases  from  the  initial 
period  to  that  of  pressure  symptoms,  and  diminishes  toward  the  close 


TEE  ADMINISTRATION  OF  DBUGS. 


77 


of  the  disease — the  stage  of  paralysis.  Ventricular  involvement  gives 
the  highest  pressure  figures.  The  following  figures  are  taken  from 
Pf aundler's  tables : 

First  stage 48  m.m.  of  mercury. 

Stage  of  pressure 52  m.m.  "  " 

Stage  of  paralysis 24  m.m.  "  " 

In  suppurative  meningitis,  the  pressure  varies  froni  10  to  37  m.m. 
of  mercury ;  in  cerebrospinal  meningitis,  from  24  to  50  m.m. ;  in 
hydrocephalus,  from  6  to  60  m.m. ;  in  tumor  of  the  brain,  from  3 
to  52  m.m.  (Quincke,  Slawyk,  Pfaundler). 

The  presence  of  an  increased  amount  of  albumin  in  pathological 
states  has  been  noted  by  Wentworth,  Quincke,  and  Pfaundler.  In 
tuberculous  meningitis  it  may  reach  0.3  per  cent. ;  in  purulent  menin- 
gitis, 0.6  per  cent. 

The  Operation  of  Lumbar  Puncture.^ — Instrument. — The  instrument 
consists  of  a  trocar  and  canula  such  as  is  employed  in  tapping  cavi- 
ties. The  best  form  of  instrument  is  that  devised 
by  Quincke  (Fig.  12).  The  canula  should  be  at 
least  one  millimetre  in  diameter.  In  order  to  de- 
termine the  pressure,  the  manometer  is  used.  This 
consists  of  a  piece  of  ordinary  glass  tubing  with 
an  attachment  of  soft  rubber  tubing.  The  manom- 
eter is  useful  to  determine  the  millimetres  of 
fluid  as  indicative  of  pressure  in  the  ventricles  and 
subarachnoid  space. 

In  infants  a  rough  way  of  estimating  the  pres- 
sure is  through  the  tenseness  of  the  anterior  fonta- 
nelle,  and  in  all  children  the  force  with  which  the 
first  few  drops  of  fluid  escape  from  the  canula. 

Indications  for  Lumbar  Puncture. — Lumbar  punc- 
ture is  performed  for  diagnostic  and  therapeutic 
purposes  in  all  cases  in  which  there  are  symptoms 
which  very  closely  simulate  meningitis,  or  in 
which  we  think  meningitis  is  actually  present. 

I  have  also  performed  lumbar  puncture  re- 
cently for  the  relief  of  symptoms  of  so-called  men- 
iiigism,  knowing  that  no  meningitis  was  present. 

Lumbar  puncture  is  performed  as  a  therapeutic  procedure  in 
cases  of  meningism,  to  relieve  pressure,  or  at  times  in  the  condition 
of  status  epilepticus ;  in  all  forms  of  meningitis ;  and  as  a  therapeutic 
procedure  in  chronic  hydrocephalus. 

It  has  recently  been  advanced  by  the  otologists  as  exceedingly 
useful  in  cases  where  meningitis  is  suspected  as  an  extension  from 
inflammation  of  the  ear  structures. 


The  Quincke  needle  for 
lumbar  puncture. 


78  INFANCY  AND  CHILDHOOD. 

The  decision  to  perform  lumbar  puncture  in  private  practice  is 
not  alwavs  easy  on  account  of  the  dread  with  which  the  laity  regard 
all  procedures  of  this  nature. 

In  pneumonia  where  there  may  be  a  suspicion  of  pneumococcus 
meningitis  and  where  there  are  signs  of  increased  cerebral  pressure  as 
evinced  by  cerebral  symptoms,  the  persistence  of  such  symptoms  may 
justify  the  physician  in  performing  lumbar  puncture. 

Indefinite  cerebral  symptoms  such  as  headache,  restlessness,  and 
convulsions  of  a  general  or  transitory  nature  are  not  indications  for 
lumbar  puncture. 

On  the  other  hand,  even  very  mild  cases  of  meningitis,  with  indefi- 
nite sopor,  muscular  weakness,  delayed  reflexes  at  the  knee,  marked 
emaciation,  and  fever  without  even  marked  rigidity  of  the  neck,  may 
justify  the  procedure  of  lumbar  puncture  on  the  ground  that  if  a 
meningitis  is  present  we  should  endeavor  to  give  the  patient  the 
benefit  of  the  therapeutic  serum  as  early  as  possible. 

Formerly  it  was  the  custom  to  refrain  from  puncture  in  doubtful 
cases ;  to-day  we  prefer  to  puncture  in  these  cases  for  reasons  before 
mentioned. 

Cases  with  meningeal  symptoms  in  which  there  is  the  history  of  a 
blow  are  proper  subjects  for  puncture,  since  it  may  be  necessary  to 
exclude  either  meningitis  or  abscess  of  the  brain. 

More  detailed  discussion  of  puncture  for  all  forms  of  meningitis 
and  hydrocephalus  will  be  taken  up  in  chapters  devoted  to  those 
subjects. 

Place  of  Puncture. — The  puncture  is  made  in  the  space  between 
the  third  and  fourth  or  the  fourth  and  fifth  lumbar  vertebrse.  This 
point  is  obtained  by  palpating  the  crests  of  the  ilium ;  an  imaginary 
tangent  to  these  crests  strikes  the  fourth  space.  The  space  above 
this  imaginary  line  will,  as  a  rule,  be  found  to  be  the  third  space. 
Puncturing  the  canal  in  the  space  between  the  sacrum  and  coccyx 
or  in  the  lower  sacral  space  offers  no  advantages  either  anatomically 
or  from  a  diagnostic  standpoint. 

Method. — General  anaesthesia  is  necessary  only  in  strong  muscu- 
lar individuals  to  reduce  resistance.  Children  who  can  be  held  do 
not  need  anaesthesia  local  or  general.  The  back  of  the  patient  is 
carefully  scrubbed  with  green  soap,  then  washed  with  alcohol  and 
ether,  and  finally  with  sublimate.  The  patient  is  laid  on  either  side 
according  to  the  convenience  of  the  operator.  The  spine  is  curved 
so  that  the  spinous  processes  may  be  distinctly  seen  and  palpated 
(Plate  III.).  ISTo  considerable  pressure  should  be  brought  to  bear 
on  the  neck,  since  in  cerebrospinal  meningitis  or  in  the  basilar  form 
of  meningitis  in  which  there  is  opisthotonos,  serious  injury  to  the 
neck  may  be  caused.     The  spine  is  curved  from  the  shoulders  and 


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TEE  ADMINISTEATION  OF  DEUGS.  79 

pelvis.  The  needle,  having  been  previonsly  boiled,  is  introduced  in 
the  median  line  betv^^een  the  spinous  processes  at  right  angles  to  a  tan- 
gent to  the  spine  (Plate IV.).  When  it  is  in  the  canal,  it  is  perceived 
that  there  is  a  lack  of  resistance,  and  that  the  point  of  the  instrnnient 
is  free.  The  canula  is  v^ithdrawn  and  the  first  drops  canght  in  a 
sterilized  test-tube.  A  second  test-tube  is  substituted  for  the  first 
after  a  few  drops  of  fluid  have  been  allowed  to  flow  out,  and  from  10 
to  50  c.c.  of  fluid  are  withdrawn,  the  amount  varying  vdth  the  pres- 
sure. If  the  fluid  flows  drop  by  drop,  20  c.c.  are  sufiicient  for  diag- 
nostic purposes  and  also  to  relieve  the  pressure.  If  there  is  opistho- 
tonos and  the  fluid  does  not  flow  well  at  first,  cautious  straightening 
of  the  neck  will  facilitate  the  outfiow.  In  infants  the  fontanelle  is  a 
good  guide  in  gauging  the  pressure.  As  soon  as  a  few  cubic  centi- 
metres of  the  fluid  have  been  withdrawn,  the  fontanelle  will  be  felt 
to  be  considerably  flattened  and  relaxed  or  even  depressed. 

If  determination  of  pressure  is  desirable,  the  manometer  tubing 
should  be  immediately  attached  as  soon  as  the  obturator  to  the  canula 
is  withdrawn,  care  being  taken  not  to  allow  any  of  the  fluid  to  es- 
cape, for  this  would  invalidate  the  determination  of  pressure.  The 
manometer  is  held  at  right  angles  to  the  spine  in  an  upward  direc- 
tion as  the  patient  lies  recumbent.  The  fluid  from  the  spinal  canal 
will  rise  in  the  manometer  to  the  point  where  the  glass  is  crooked ;  it 
must  not  be  allowed  to  flow  over  the  curve ;  the  measurement  is  then 
taken  of  the  height  of  the  column  of  liquid.  After  this  is  done  the 
manometer  tube  is  lowered  and  the  fluid  is  allowed  to  escape.  In 
ordinary  lumbar  puncture  the  determination  of  pressure  is  not 
necessary.  Heubner  has  withdrawn  100  c.c,  but  the  removal  of  such 
large  quantities  is  unnecessary  and  may  be  followed  by  hyperpyrexia 
and  collapse.  I  rarely  withdraw  more  than  30  to  50  c.c.  If  there  is 
a  dry  tap,  the  canula  should  be  withdrawn  and  a  second  attempt 
made  on  the  following  day.  A  dry  tap  may  be  caused  by  a  flbrin 
clot  or  by  the  falling  of  the  cauda  equina  in  front  of  the  opening  of 
the  canula.  The  fluid  may  be  viscid  and  refuse  to  flow.  In  that  case 
the  fluid  should  not  be  aspirated  with  a  syringe,  since  in  the  experi- 
mental laboratory  this  method  has  been  proved  to  be  hazardous.  After 
puncture,  the  canula  is  rapidly  withdrawn  and  the  wound  dressed 
with  sterile  gauze. 

Dangers  of  Lumbar  Puncture. — Lumbar  puncture  if  carried  out  as 
above  indicated  is  rarely  followed  by  ill  effects  or  death.  But  there 
are  enough  cases  of  fatal  issue  during  or  after  the  lumbar  puncture 
in  the  literature  to  make  us  mindful  of  the  fact  that  in  exceptional 
cases,  esi^ecially  when  patients  have  been  ill  for  some  time,  and  in 
cases  of  tumor  of  the  brain,  such  an  issue  is  always  possible. 

Therefore  if  lumbar  puncture  is  performed  in  cases  where  there 


80 


INFANCY  AND  CHILDHOOD. 


Fig.  13. 


are  reasons  to  assume  the  existence  of  a  cerebral  tumor,  those  inter- 
ested should  be  warned  of  the  possibility  of  an  untoward  issue. 

Introduction  of  Fluids  Containing  Drugs  or  Sera  Into  the  Spinal  Canal. 
- — ISTow  that  cerebrospinal  meningitis  is  treated  with  sera  by  the  so- 
called  sub-dural  method,  it  becomes  necessary  aftar 
the  withdrawal  of  the  fluid  in  cases  of  meningitis 
to  introduce  the  therajieutie  serum  into  the  canal. 
As  a  rule  we  introduce  in  quantity'  as  much  as 
we  have  withdrawn  from  the  patient.  It  is  cus- 
tomary in  some  quarters  to  attach  a  syringe  con- 
taining the  therapeutic  serum  or  fluid  to  the  canula 
of  the  puncture  needle,  and  thus  slowly  inject  the 
fluid  into  the  canal.  This  is  not  as  desirable  a 
procedure  as  using  a  so-calkd  Quincke  funnel  for 
this  purpose.  The  Quincke  funnel  consists  of  a 
small  glass  test-tube,  drawn  out  into  a  funnel- 
shaped  point,  which  is  attached  to  a  piece  of  tubing 
(Fig.  13).  As  soon  as  the  fluid  has  escaped  to  the 
desired  amount  from  the  spinal  canal,  the  tubing 
is  attached  to  the  tip  of  the  canula,  and  the  funnel 
being  filled  with  the  therapeutic  agent,  is  somewhat 
depressed  below  the  level  of  the  opening  in  the 
canal  in  order  to  allow  the  air  which  may  have 
been  in  the  tubing  to  escape.  The  canula  is  then 
raised  slightl}'',  and  it  will  be  observed  that  the 
fluid  will  flow  quite  freely  into  the  spinal  canal. 
The  23atient  remains  in  the  recumbent  position 
during  the  operation,  as  has  been  indicated  in  the 
paragraph  on  technique. 

All  fluid  introduced  into  the  spinal  canal 
should  have  been  previously  warmed  carefully  to 
the  temperature  of  the  body,  and  should  be  intro- 
duced slowly.  Eapid  introduction  of  the  fluid  will 
cause,  in  exceptional  cases,  collapse  and  especially 

This 
has  ha])pened  twice  in  the  author's  experience, 
though  no  fatal  issue  resulted.  It  has  not  occurred  with  the  use  of 
ihe  funnel. 


QuiiiL-ke  funnel,  tub- 
ing ;m(l  needle  at- 
tachert  for  introduc- 
ing   serum     or     fluids  .  .  .  »  .         . 

into  the  subarachnoid    if  a  syriuge  IS  uscd  ccssation  of  respiration 

space.  ./         o 


SECTION  II. 

NUTRITION  AND  INFANT-FEEDING. 

PRINCIPLES   UNDERLYING    THE    PROCESSES    OF    NUTRITION. 

There  is  no  division  of  jDediatrics  which  exceeds  in  importance 
that  of  infant-feeding.  In  fact  the  subject  of  infant-feeding  is  not 
only  difficult  to  master,  but  requires  thorough  study  and  experience 
to  carry  it  to  a  successful  issue.  The  practitioner,  therefore,  will 
find  that  it  is  absolutely  necessary  for  him  to  understand  the  prin- 
ciples underlying  the  art  of  infant-feeding,  in  order  to  attain  any 
success  in  practice  in  this  field.  Though  great  advances  have  been 
made  in  the  study  of  infant-feeding  in  the  past  decade,  we  cannot  say 
that  the  art  of  applying  certain  principles  of  nutrition  to  the  feeding 
of  infants  has  attained  its  highest  perfection.  We  cannot  explain 
why  one  infant  will  thrive,  whereas  another,  fed  according  to  the 
same  method,  will  fail  to  thrive  and  lose  ground. 

To  a  certain  extent  the  subject  of  infant-feeding  is  still  empirical, 
although  it  may  be  said  that  empiricism  is  gradually  but  surely  dis- 
appearing from  this  field  of  pediatrics.  It  is  the  exceptional  infant 
which  to-day  refuses  to  thrive,  and  puzzles  the  most  brilliant  master 
of  the  art,  but  the  vast  majority  of  children  can  certainly  be  fed 
according  to  principles  well  established  and  laid  out  at  the  disposal 
of  the  general  practitioner. 

If  we  study  these  principles  of  nutrition  closely  we  shall  see  that 
they  must  to  a  certain  extent  conform  to  what  is  known  to  take  place 
not  only  in  the  body  of  the  infant,  but  also  in  that  of  the  adult. 
There  are  certain  exceptions  which  must  be  made  as  regards  the 
infant,  on  account  of  its  rapidly  growing  organism  and  the  fact  that 
the  cells  of  the  body  are  not  only  being  replaced  rapidly,  but  the 
tissues  at  the  same  time  are  undergoing  rapid  increment.  As  that 
of  the  adult,  the  body  of  the  infant  and  child  is  constantly  suffering 
a  loss  of  its  principal  elements,  consisting  of  water,  albumin,  fat, 
and  mineral  salts.  This  loss  will  vary  within  wide  limits,  accord- 
ing to  the  needs  of  each  individual  subject.  The  infant  body  must 
take  in  sufficient  nourishment  not  only  to  make  up  for  the  constant 
loss  and  destruction  of  cell  life,  but  also  for  the  increase  and  growth 
of  the  body  and  development  of  various  tissues,  in  this  respect  dif- 
fering; from  the  adult.  The  loss  of  nitrosjenous  substances  and  fat 
must  be  made  up  by  equivalents  in  the  food ;  at  the  same  time  in  the 

6  81 


82  -  NUTEITION  AND  INFANT  FEEDING. 

infant  and  child  enough  must  be  furnished  to  allow  for  the  rapid 
increase  of  weight  and  the  growth  of  tissue  throughout  the  body. 

There  are  other  substances,  such  as  collogen,  chondrogen,  keratin, 
mucin,  and  lecithin,  which  are  needed  in  the  infant's  economy  as 
well  as  in  that  of  the  adult,  and  these  are  excreted  by  the  infant  and 
child  as  in  the  adult.  If  fat  and  albumin  are  taken  in  sufficient 
quantity  into  the  system,  the  loss  in  these  substances  is  compensated 
for  by  the  splitting  up  of  the  nitrogenous  and  fatty  elements  of  the 
food. 

It  will  enlighten  the  student  to  familiarize  himself  with  the  role 
played  by  the  various  food  elements  in  replacing  the  loss  of  tissue 
in  the  economy.  These  primary  food  elements  are  principally  water, 
mineral  salts  (inorganic  and  ash  residue),  proteids,  or  albumin,  fat, 
and  carbohydrates. 

Water. — Water  plays  by  far  the  principal  role  in  the  composition 
of  the  body.  The  tissues  of  the  body  contain  from  66  to  70  per 
cent,  of  water  in  the  newborn  infant  and.  child,  as  compared  with 
64  per  cent,  in  the  adult.  It  exists  in  this  high  percentage  in  most 
of  the  organs  of  the  body,  with  the  exception  of  the  bones,  cartilage, 
teeth,  and  fatty  tissue.  The  remaining  organs,  if  these  be  excluded, 
will  contain  78  per  cent,  of  water.  Water  is  not  only  essential  to 
the  adult  body,  but  is  a  very  important  element  of  nutrition  in  in- 
fants. We  see  this  exemplified  in  disease,  especially  when  the  drain 
on  the  system  is  great  and  the  loss  of  fluids  of  the  body  is  consider- 
able, as  in  cholera  infantum,  or  in  intestinal  disease,  acute  and 
chronic.  Infants  show  the  drain  of  water  from  the  economy  very 
rapidly,  and  our  treatment  in  disease  is  directed  in  a  great  many 
instances  to  supplying  the  loss  of  water  caused  by  the  diseased  con- 
dition. The  circulation  of  the  blood  and  lymph  depends  on  the  pres- 
ence of  a  fixed  percentage  of  water;  in  the  former  case  78  per  cent., 
in  the  latter  96  per  cent,  of  these  tissues  is  composed  of  water.  Di- 
gestion, both  in  the  adult  and  the  child,  must  have  for  its  successful 
completion  a  certain  amount  of  water  element.  Muscular  and  nerve 
force  are  greatly  dependent  on  water  and  are  regulated  by  it. 

The  body  excretes  water  through  the  urine,  the  fseces,  the  lungs, 
the  skin,  and  the  amount  excreted  varies  widely,  not  only  in  the 
adult,  but  in  the  infaut  and  child. 

It  is  not  our  aim  here  to  enter  into  any  specific  details  of  the 
role  played  by  water  in  the  economy,  but  from  what  has  been  said 
it  can  be  seen  that  inasmuch  as  fully  86  per  cent,  of  the  breast-fed 
infant's  food  consists  of  water,  nature  has  put  great  store  by  this 
element  of  foodstuff  which  is  taken  into  the  infant's  body  daily. 
Moreover,  water  given  in  disease  will  sometimes  maintain  life,  but 
it  cannot  maintain   the  proper  nutrition   of  the  body  without  the 


PEINCIPLES  UNDEEL¥ING  PBOCESSES  OF  NUTRITION.  83 

addition  of  other  elements  of  food.  This  is  seen  in  the  treatment 
of  gastro-enteritis.  We  may  tide  over  a  critical  period  in  the  disease 
by  the  administration  of  water  exclusively,  without  endangering  life 
through  starvation.  During  this  period,  however,  the  nitrogenous 
waste  of  the  body  is  not  replaced  by  any  equivalent  article  of  food, 
and  though  we  may  continue  on  a  water  diet  for  a  little  while,  it 
becomes  imperative  after  a  time  to  add  other  substances  to  the  food. 

Mineral  Salts. — Mineral  salts  exist  in  most  of  the  tissues  of  the 
body  and  in  all  organized  tissue  which,  when  burnt,  leaves  an  ash 
residue.  Sodium,  potassium,  lime,  magnesium,  and  phosphorus, 
with  a  trace  of  iron,  are  the  principal  mineral  substances  found  in  the 
body.  Just  as  water  is  necessary  to  the  maintenance  of  the  nutrition 
of  the  body,  so  are  the  mineral  salts.  The  actual  growth  of  the  child 
in  the  first  six  months  amounts  to  150  to  300  grammes;  in  the  fol- 
lowing six  months,  100  to  200  grammes  per  week.  In  the  second 
year  the  body-weight  is  increased  by  50  to  100  grammes  per  week, 
and  from  this  time  on  the  increase  declines.  The  skeleton  in  the 
first  year  increases  fully  2.2  pounds,  or  one  kilo,  in  weight,  and  the 
earthy  phosphates  being  an  important  element  in  the  composition  of 
the  bones,  3.5  grammes  of  phosphate  of  calcium  are  used  every  week 
during  the  first  year  by  the  skeleton. 

This  great  demand  of  the  skeleton  for  lime  salts  is  met  by  the 
food  of  the  infant — the  milk — much  better  and  in  a  more  assimi- 
lable state  than  by  any  food  taken  by  the  adult  subject.  The  muscles 
also  need  a  certain  amount  of  lime  salts,  and  a  dearth  of  mineral 
salts  becomes  evident  much  more  quickly  in  the  infant  and  child 
than  it  does  in  the  adult.  We  see  this  exemplified  in  artificially  fed 
infants,  whose  food  (cows'  milk)  is  not  as  well  assimilated  as  is  the 
mother's  milk  by  the  naturally  fed  infant.  Whereas  800  c.c.  of 
mother's  milk  contain  1.2  grammes  of  potassium  phosphate,  0.2 
grammes  of  lime  phosphate,  0.6  grammes  of  sodium  chlorid,  and  2.5 
milligrammes  of  iron,  and  these  are  completely  assimilated  by  the 
infant,  the  same  salts  in  cows'  milk  are  excreted  to  a  great  extent 
by  the  intestine  (Bunge),  and  for  this  reason,  in  part,  rachitis  and 
disturbances  of  nutrition  of  the  bones  are  very  common  in  artificially 
fed  infants. 

Proteids. — ISText  to  water,  according  to  Munk,  the  most  important 
constituents  of  the  body  are  the  proteids ;  they  make  up  10  per  cent. 
of  the  tissues.  The  proteids  in  the  food  not  only  replace  the  general 
nitrogenous  loss  of  cell  tissue  in  the  body,  but  with  other  substances, 
the  so-called  proteid-saving  elements  of  the  food,  such  as  fat,  add  to 
the  general  nitrogenous  store  in  the  body.  ISTitrogenous  cell  waste 
can  be  replaced  only  by  the  proteids  of  the  food.  Growth  of  body 
is  accomplished  by  the  proper  supply  of  albumin  in  the  food.     Other 


84  '  NUTBITIOX  AND  IN  FAN  I  FEEDING. 

substances,  such  as  fat.  added  to  the  albuminous  substances  of  the 
food  may  replace  nitrogenous  waste  in  the  body;  increase  of  weight 
or  growth  can  be  accomplished  only  by  the  proteid  elements  of  the 
food. 

The  bone  tissue,  cartilage,  tendon,  connective  tissue,  need  pro- 
teids  also,  as  has  been  stated  above,  to  replace  the  waste  and  accom- 
]3lish  the  growth  of  these  tissues.  The  breast-fed  infant  obtains  in 
its  food  a  casein  and  also,  in  small  quantities,  lactalbumin.  From 
these  the  body  forms  not  only  the  nitrogenous  cell  elements,  but 
mucin,  chondrin,  glutin,  elastin,  keratin,  which  are  derivatives  of 
albumin,  and  whose  mode  of  formation  is  still  obscure  (Munk). 

Fats. — Animal  fats  are  composed  of  varying  proportions  of  olein, 
palmitin,  and  stearin.  Their  presence  in  the  body  varies,  within 
certain  limits,  from  9  to  23  per  cent,  of  the  body-weight.  Fat  is 
found  in  the  body  in  the  form  of  fat-deposits.  It  is  deposited  under- 
neath the  skin,  in  the  muscle,  in  the  nerve  tissue,  around  the  various 
organs  of  the  body.  It  plays  an  important  role  in  the  maintenance 
of  the  warmth  of  the  body  and  exerts  a  non-conducting  role,  pre- 
venting radiation.  As  a  food  it  cannot  replace  the  proteids.  Fat 
combined  with  proteid  substances  in  the  food  may,  however,  act  as 
a  nitrogenous-saving  substance.  Thus,  in  muscular  work  the  body 
needs  a  great  amount  of  fat.  If  combined  with  the  proteidb,  nitrog- 
enous waste  is  saved  and  fat  is  burnt  up  in  doing  the  muscular  work, 
and  it  may  even,  if  taken  in  sufficient  quantities,  cause  an  accumu- 
lation of  fat  in  the  body.  To  cause  gTowth  in  nitrogenous  tissue, 
however,  the  presence  of  a  sufficient  amount  of  proteid  in  the  food  is 
absolutely  necessary.  Thus,  while  fat  and  albumin  may  replace 
waste  caused  by  muscular  action,  both  in  the  fatty  and  nitrogenous 
tissues  of  the  body,  fat  cannot  add  to  the  nitrogenous  gi'owth  of 
cell  tissue. 

The  infant  and  child  obtain  the  fatty  elements  of  the  food  in  the 
milk.  Whereas  97.5  per  cent,  of  the  fat  in  mother's  milk  is  assimi- 
lated, only  93.5  per  cent,  of  the  fat  of  the  cows'  milk  is  assimilated 
by  the  infant.  The  artificially  fed  infant,  therefore,  is  deprived  of 
an  important  food  element  to  the  extent  indicated,  and  in  many  cases 
assimilation  of  fats  in  the  artificially  fed  infant  is  even  much  more 
imperfect  in  practice  than  is  indicated  by  the  percentage  named. 
For  in  some  infants,  if  the  fat  in  the  cows'  milk  is  increased  beyond 
a  certain  percentage,  symptoms  of  intestinal  indigestion  manifest 
themselves  in  a  so-calk^d  fat  diarrhoea.  In  other  infants  the  difficul- 
ties of  fat  assimilation  are  shown  in  inordinate  constipation  and 
anaemia,  especially  if  the  percentage  of  fat  in  the  food  is  in  excess 
of  4  per  cent.  Such  infants  must  be  fed  on  a  limited  amount  of  fat 
because  of  the  difficulty  of  assimilation  of  fat  of  cows'  milk. 


METABOLISM  IN  THE  NUBSING  INFANT.  85 

Carbohydrates. — According  to  Munk,  carbohydrates  exist  in 
various  tissues  of  the  body,  most  abundantly  in  the  liver,  in  the  form 
of  glycogen  and  grape  sugar ;  in  the  human  milk,  in  the  form  of  milk 
sugar,  3^  to  9  per  cent.,  in  the  muscles,  in  the  form  of  glycogen,  0.3 
to  0.9  per  cent.,  with  some  grape  sugar.  The  blood  and  lymph  con- 
tain a  small  quantity  of  grape  sugar  (0.1-0.15  per  cent.).  We  find 
glycogen  in  all  growing  tissues,  and  the  formation  of  glycogen  seems 
to  be  a  function  of  the  young  cell. 

The  infant  obtains  its  carbohydrates  for  the  most  part  from  the 
milk,  where  they  exist  in  the  form  of  milk  sugar.  Milk  sugar  as 
contained  both  in  human  and  in  cows'  milk  is  assimilated  by  the 
infant  completely,  so  that  in  this  respect  the  infant  is  not  deprived 
in  artificial  feeding  of  any  food  element. 

Carbohydrates  play  much  the  same  role  in  the  economy  as  do 
the  fats  in  saving  nitrogenous  waste.  Whereas  we  can  make  up 
to  a  certain  extent  nitrogenous  waste  by  the  addition  of  fats  and 
carbohydrates  to  the  food,  the  nitrogenous  substances  of  the  body 
themselves  can  be  reproduced  only  by  nitrogenous  proteid  substances. 
It  is  self-evident,  therefore,  that  in  infant-feeding,  though  we  may 
produce  fat  by  carbohydrates,  saving  to  a  certain  extent  nitrogenous 
waste,  we  cannot  do  this  for  any  leng-th  of  time  without  producing 
an  actual  proteid  starvation  unless  we  supply  with  the  carbohydrates 
and  the  fat  a  certain  amount  of  proteids. 

We  see  this  well  illustrated  in  substitute  infant-feeding  in  cases 
of  difficult  proteid  digestion.  We  can  aid  digestion  of  the  proteids 
by  the  addition  of  carbohydrates.  We  can  even  cause  the  formation 
and  deposit  of  fat  to  a  gTeat  extent  by  the  addition  to  the  food  of  car- 
bohydrates. We  can  save  nitrogenous  cell  waste  by  the  addition  of 
carbohydrates  to  the  food.  If  we  continue  this  mode  of  feeding  for 
any  length  of  time  we  can  see  clinically  the  effects  of  the  dearth  of 
proteids  on  the  economy.  The  infants  after  a  period  of  time  do  not 
increase  in  weight,  the  tissues  of  the  body  suffer  in  nutrition,  and 
anaemia  appears.  We  then  must  supply  with  the  carbohydrates  an 
increased  amount  of  proteids. 

METABOLISM   IN    THE    NURSING   INFANT. 

The  principles  of  metabolism  and  nutrition  which  have  been 
established  in  the  adult  apply  in  a  general  way  to  the  nursing  infant. 
In  the  adult  the  food  supplies  the  waste  and  maintains  body-heat  and 
energy,  but  in  the  infant  it  must  also  furnish,  in  addition  to  these, 
the  material  for  body-growth.  The  main  physiological  character- 
istic, therefore,  of  infancy  and  childhood  is  that  it  is  a  period  of 
growth,  and  the  younger  the  infant  the  gTeater  the  growth. 


86  '  NUTRITION  AND  INFANT  FEEDING. 

Milk,  the  food  of  the  breast-fed  infant,  contains  all  the  necessary 
food  elements  to  maintain  nutrition,  produce  energy,  warmth,  and 
to  aid  in  cell-growth.  In  considering  metabolic  processes  in  the 
infant  we  express  the  energy  and  warmth-producing  equivalents  of 
the  food  introduced  into  the  body  by  the  term  calories.  A  calorie 
is  the  heat  produced  by  raising  1  kilogi'am  of  water,  1°  C,  and  is 
the  unit  of  heat.  In  the  infant  there  is  a  deficit,  as  in  the  adult,  of 
10  per  cent,  between  the  raw  calories  (food)  introduced  into  the  body 
and  the  actual  number  of  calories  produced.  In  other  words,  all  the 
food  is  not  absorbed.  We  do  not  know  as  yet  how  much  to  allow  in 
estimating  the  number  of  caloric  equivalents  for  the  excreta,  urea, 
carbonic-acid  gas,  and  water.  With  the  above  defects  yet  to  be  eluci- 
dated by  further  investigations,  we  can  present  the  following  facts : 

A  breast-fed  infant,  three  months  of  age,  weighs  5  kilos,  takes 
800  c.c.  of  breast  milk  in  the  twenty-four  hours,  and  increases  0.25 
to  0.35  grammes  a  day.  A  litre  of  human  milk  contains:  casein 
16  grammes,  fat  35  grammes,  milk  sugar  65  grammes.  The  adult, 
on  the  other  hand,  takes  daily  1.7  of  proteids,  0.85  of  fat,  7.5  of 
carbohydrates  per  kilo  of  body-weight.  The  nursing  infant,  there- 
fore, takes  per  kilo  of  body-weight  twice  as  much  proteids  and  three 
times  as  much  fat  as  the  adult,  the  milk  sugar  being  converted  into 
fat  values.  In  the  adult  the  ratio  of  proteid  to  other  food  substances 
is  as  1  to  5  in  the  food ;  whereas  in  the  infant  taking  human  milk  the 
ratio  is  as  1  to  6,  and  with  cows'  milk,  1  to  3. 

According  to  Rubner,  the  value  of  1  gramme  of  proteid  sub- 
stance of  the  milk  is  4.4  calories,  1  gramme  of  milk  sugar,  3.9  calor- 
ies, and  1  gramme  of  fat,  9.2  calories.  One  litre  of  human  milk  is 
equal  to  650  calories,  and  1  litre  of  cows'  milk  to  700  calories.  An 
infant  three  months  of  age,  therefore,  drinking  800  grammes  of 
breast  milk  would  take  in  500  calories  daily,  and  if  it  weighed  5 
kilogrammes  it  would  be  taking  100  calories  per  kilogramme  of  body- 
weight  a  day.  Bonnoit  found  by  experiment  that  an  infant  pro- 
duced 80  calories  per  kilogramme  of  body-weight  in  twenty-four 
hours,  and  if  we  deduct  10  per  cent,  from  the  raw  caloric  equivalent 
of  the  food  we  would  have  almost  as  many  calories  introduced  into 
the  body  as  the  body  produced. 

The  need  of  100  calories  per  kilogramme  remains  constant  during 
the  first  year  of  life,  diminishes  slightly  in  the  second  year,  with  the 
following  exceptions :  During  the  first  ten  days  the  infant  uses  up 
only  40  to  50  calories,  and  the  increase  of  weight  is  accomplished 
mostly  by  the  watery  substances  of  the  food.  Rulmer  and  Heubner 
found  that  of  the  100  calories  used  up  by  the  infant,  20  were  util- 
ized to  supply  body-waste  and  80  were  burned  up  to  produce  heat. 
Therefore  the  necessary  hcat-])ro(liu'ing  calories  are  much  higher  in 


METABOLISM  IN  TEE  NUESING  INFANT.  87 

the  infant  as  compared  to  the  adult,  as  are  also  the  number  of  calories 
necessary  to  increase  body-weight.  This  greater  need  on  the  part 
of  the  infant  is  explained  by  Eubner  by  the  fact  that  in  proportion 
to  their  body-weight,  infants  present  a  greater  surface  area  than  do 
adults,  and  therefore  lose  much  more  heat  in  a  given  time  than  adults. 
Therefore  the  extent  of  loss  of  heat  is  dependent  on  the  extent  of 
surface  exposed,  and  allowing  for  this  and  not  calculating  the  needs 
of  the  organism  by  weight,  we  find  that  both  the  child  and  the  adult 
need  the  same  number  of  calories. 

The  following  shows  the  number  of  calories  produced  by  the 
various  constituents  of  the  food  in  the  adult  and  in  the  infant. 

Of  100  calories  in  the  food  taken  in  by  the  adult,  proteids  pro- 
duce 19,  fats  30,  carbohydrates  51.  Of  100  calories  in  the  milk 
taken  by  the  infant,  proteids  produce  18,  fat  53,  carbohydrates  29. 
In  the  infant,  therefore,  the  fat  is  the  chief  heat  producer.  It  is 
also  nitrogen-saving,  inasmuch  as  the  latter  is  used  for  cell-growth. 

After  the  first  year  growth  is  not  so  active  and  less  fat  is  needed, 
and  this  constituent  is  replaced  by  carbohydrates.  The  following 
table  illustrates  this : 

Weight- 
Age,  kilogrammes. 

3  davs 3.0 

6     "■      3.2 

4  months 6.0 

Ij  years 9.0 

2i  "  "         10.0 

11       "        23.4 

Adult 70.0 

Mineral  Salts. — The  infant  in  its  milk  takes  more  mineral  salts 
into  the  body  than  the  adult,  kilo  for  kilo  of  body-weight.  They  are 
utilized  in  the  growth  of  the  infant. 

Excreta. — Much  is  to  be  learned  as  to  how  much  should  be  allowed 
to  the  excreta  in  calculating  the  necessary  calories  used  up  by  the 
infant  organism.  By  the  excreta  we  mean  urea,  water,  and  carbonic 
acid  gas.  Rubner  and  Heubner  have  shown  that  an  infant  in  the 
first  six  months  excretes  less  urea  than  the  adult.  In  the  second  half 
year  the  infant  excretes  more  urea  than  the  adult,  and  this  increases 
until  the  tenth  year.  In  proportion  to  its  weight  the  infant  takes 
more  nitrogenous  substance  into  the  body  than  it  excretes  in  the 
form  of  urea. 

During  the  first  six  months,  the  growth  of  the  infant  being  most 
active,  this  is  markedly  so,  and  the  nitrogen  is  retained  to  a  greater 
extent  in  the  system  during  the  first  six  months  of  infancy.  Michael 
has  found  that  the  nitrogen  excreted  in  the  fseces  and  urine  and  the 
proteids  of  the  food  retained  in  the  body  were  one-fourth  of  the 
whole  increase  of  weio-ht  in  the  newborn  infant. 


Proteids. 

Fats. 

Carbohydrates. 

2.4 

2.8 

2.9 

3.7 

4.3 

4.4 

3.8 

4.5 

4.6 

4.4 

4.0 

8.9 

3.6 

2.7 

15.0 

2.8 

2.0 

11.4 

1.7 

0.85 

7.5 

88  NUTRITION  AND  INFANT  FEEDING. 

Water, — Kubner  and  Heubuer  found  that  of  530  grammes  of 
water  taken  by  the  ten-weeks-old  child  into  the  body,  505.5  grammes 
were  excreted,  and  of  this  quantity  more  than  half  was  excreted  in 
the  form  of  urine. 

Carbonic  Acid  Gas  (COo). — Voit,  Pettenkofer,  Forster,  and 
Mensi  have  shown  that  from  birth  to  the  tenth  year  of  life  the  child 
excretes  one  and  a  half  to  two  and  a  half  times  as  much  carbonic  acid 
gas  as  the  adult,  and  this  is  practically  furnished  by  the  fats.  Eubner, 
Heubner,  and  Bendix,  however,  have  shown  that  a  breast-fed  infant 
weighing  5  kilos  (11  pounds)  exhales  per  square  metre  of  hody- 
surface  less  CO2  than  the  adult. 

Munk  thinks  that  the  proteids  are  utilized  in  the  organism  to 
form  carbonic  acid  gas.  The  principal  facts,  therefore,  adduced  in 
regard  to  the  breast-fed  infant  in  connection  with  metabolism  are 
that  the  infant  in  the  course  of  the  first  six  months  needs  for  the 
production  of  warmth,  potential  energy,  and  increase  of  weight  100 
calories  per  kilo  of  body-weight.  Eighty  of  these  calories  are  util- 
ized for  warmth  and  energy  and  20  for  increase  of  cell-growth.  If, 
therefore,  an  infant  takes  only  80  calories  into  its  body,  its  weight 
will  remain  stationary.  If  it  takes  less,  it  will  have  to  utilize  its 
own  tissues  in  order  to  live,  and  emaciation  will  result. 

Metabolism  in  the  Bottle-fed  Infant. — What  has  been  said  of 
the  nursling  at  the  breast  applies  in  a  general  way  to  the  bottle-fed 
infant,  with  the  exception  that  Rubner  and  Heubner  have  shown  that 
an  artificially  fed  infant  needs  120  calories  instead  of  100  per  kilo 
of  body-weight  to  maintain  warmth,  energy,  and  increase  in  weight. 
They  explain  the  need  of  the  additional  20  calories  taken  into  its 
body  by  the  bottle-fed  infant  by  the  necessity  of  extra  work  on  the 
part  of  the  intestine  in  digesting  cows'  milk.  It  is  of  interest  that 
the  infant,  notwithstanding  the  fact  that  cows'  milk  is  so  entirely 
different  in  its  composition  from  human  milk,  can  utilize  this  food 
in  the  production  of  caloric  energy.  The  artificially  fed  infant  must 
transform  a  proteid  foreign  to  the  body  to  one  of  a  nature  similar  to 
that  of  human  milk.  The  utilization  by  the  infant  of  cows'  milk  is 
not  perfect,  for  we  have  the  following  differences  between  the  breast- 
and  bottle-fed  infant,  which  are  apparent  on  the  surface. 

The  increase  of  weight  is  irregular  in  the  bottle-fed  infant  as 
compared  to  the  regular  increase  in  the  breast-fed  infant.  The  daily 
fluctuations  of  temperature  in  the  bottle-fed  infant  are  irregular  as 
compared  to  the  fluctuations  in  the  breast-fed  infant.  The  bottle- 
fed  infant,  as  a  rule,  is  an  ansemic  child;  the  breast-fed  infant  the 
contrary.  The  bottle-fed  infant  may  become  rachitic  even  from 
birth.  It  is  thought  to  be  more  susceptible  to  infection,  less  resistant 
to  the  inroads  of  disease.     It  is  deprived  of  the  enzymes  and  alexins 


IRE  FOOD  OF  TEE  INFANT.       '  89 

present  in  the  imman  milk.  Therefore  the  metabolic  processes  in 
the  infant  fed  upon  the  bottle  and  those  on  the  breast  must  necessarily 
diifer,  and  in  this  respect  our  scientific  data  are  still  incomplete. 
Human  milk  cannot  be  completely  replaced  bv  any  form  of  animal 
milk. 

THE   FOOD    OF    THE   INFANT. 

The  study  of  infant  feeding  naturally  divides  itself  into  the  con- 
sideration of  the  infants  fed  at  the  breast  by  the  natural  method  and 
those  fed  with  some  substitute  for  the  breast,  such  as  cows'  milk  or 
infant  foods,  or  dilutions  of  the  same. 

Human-breast  Milk. — Colostrum. — From  the  third  or  fourth 
month  of  pregnancy  the  human  breast  begins  to  show  signs  of  func- 
tionating and  secretes  a  yellowish-white,  thick,  sticky  fluid  called 
colostrum.  As  the  period  of  pregnancy  approaches  the  seventh 
month  the  secretion  of  colostrum  becomes  more  active,  and  its  phys- 
ical properties  are  those  of  a  thin,  grayish-yellow  fluid  which  exudes 
from  the  breast-nipple  under  slight  pressure. 

Physical  Properties.- — Colostrum  differs  from  the  normal  milk 
secretion  in  being  of  a  light-yellowish  or  grayish-yellow  color.  It  is 
markedly  alkaline  in  reaction.  It  is  rich  in  fats  and  proteids,  poor 
in  casein,  in  that  the  albumin  exists  in  relatively  gTeater  quantity. 
The  composition  of  the  colostrum  varies  from  time  to  time  until  the 
period  approaches  when  it  is  replaced  gradually  by  the  normal  milk 
secretion.  This  occurs  about  twelve  days  after  birth  in  a  normally 
functionating  breast.  At  this  time  colostrum,  as  such,  should  have 
disappeared  (Plate  V.). 

The  average  composition  of  colostrum,  according  to  Camerer  and 
Soldner,  is  as  follows : 

Water 86.70 

Proteids 3.07 

Fat 3.34 

Milk  sugar 5.27 

Ash 0.40 

It  has  a  speciflc  gravity  of  1.040  to  1.060.  Microscopically  colos- 
trum, in  addition  to  fat-globules,  leucocytes,  pavement  epithelium, 
granules  of  casein  and  phosphates,  contains  the  so-called  colostrum 
corpuscles  and  the  crescent-shaped  bodies  of  Lourie.  The  fat-globules 
have  similar  physical  properties  to  the  fat-globules  of  the  milk,  and, 
as  in  human  milk,  they  are  found  associated  with  the  crescent-shaped 
bodies  of  Lourie,  to  be  described  (Fig.  14). 

The  colostrum  corpuscle  is  a  spherical  body  four  or  five  times 
larger  than  the  milk-globule,  and  measuring  13  /a  to  40  /^  in  diameter. 
It  contains  fat  in  the  granular  and  globular  state.     The  colostrum 


90 


XUTFITIOX  AXD  INFANT  FEEDING. 


corpuscle  is  looked  iij)oii  by  some  as  a  degenerated  leucocyte  (Czerny). 
The  coloring-matter  of.  colostrum  is  contained  in  the  colostruna  cor- 
puscle. These  colostrum  corpuscles  are  the  distinguishing  feature 
of  colostrum  as  compared  to  milk,  and  so  long  as  they  are  present  in 
the  milk  to  any  appreciable  extent  it  cannot  be  considered  as  fit,  in 
every  sense,  for  continued  infant-feeding.  If  lactation^  for  one 
reason  or  another,  is  interrupted,  the  colostrum  corpuscles  reappear 
in  the  milk.  When  lactation  is  again  established  these  corpuscles 
should  disappear  from  the  secretion.     Should  colostrum  persist  for 

Fig.  14. 


Colostrum  corpuscles  and  crescents  of  Lourie.      (Marfan.) 


too  long  a  period  in  the  breast,  the  infant,  as  a  rule,  does  not  thrive. 
It  can  thus  be  seen  that  from  the  twelfth  day  or  thereabout  after 
delivery  of  the  infant,  the  milk  which  takes  the  place  of  the  so-called 
colostrum  should  contain  either  no  colostrum  corpuscles  at  all  or  in 
a  vanishing  quantity. 

In  addition  to  the  colostrum  corpuscle,  colostrum  contains  an 
interesting  crescent-shaped  body,  described  in  connection  with  human 
milk,  which  is  seen  adherent  to  the  external  border  of  the  fat-globule. 
Some  of  these  colostrum  crescents  may  present  an  intimation  of  a 
nucleus.  They  have  been  described  by  Lourie,  and  can  be  seen  by 
extracting  the  fat  from  the  colostnini  and  staining  with  methylene 
blue  or  thionine. 

Milk.' — Milk  may  appear  in  the  breasts  the  fifth,  sixth  or  tenth 
day  after  delivery.  In  exceptiDiial  (-a.-^es  I  have  seen  the  milk  de- 
layed as  late  as  the  third  week;  or  it  may  diminish  after  having 
ai)]>eared  and  then  increase  after  a  few  weeks. 

Our  knowledge  of  the  cheiiiisiry  of  liniii;iii   milk   is  still   incom- 


TEE  FOOD  OF  THE  INFANT.  91 

plete  and  lacking  in  many  essentials  which  would  aid  the  physician 
in  his  work.  Older  analyses  of  human-breast  milk  give  the  gross 
amount  of  proteids,  and  Hoppe-Seyler  suggested  that  the  casein  of 
human  milk,  or  for  that  matter  cows'  milk,  should  be  determined 
aside  from  the  total  quantity  of  proteids.  Therefore  the  older  analyses 
which  deal  with  the  total  amount  of  proteids  under  the  heading  of 
casein  are  not  as  useful  to  us  to-day  as  the  more  modern  analyses 
which  distinguish  between  the  casein  and  other  proteids  in  the  milk. 
The  great  importance  of  this  point  will  become  more  apparent  when 
we  study  the  composition  of  cows'  milk  and  attempt  to  modify  it  to 
conform  to  the  theoretical  composition  of  human  milk. 

C omposition. — The  composition  of  breast  milk  varies  not  only  in 
different  women  and  the  same  woman  at  various  periods  of  lactation, 
but  in  the  same  woman  at  different  times  of  the  day.  The  result  is 
that  various  analyses  differ  with  each  other  in  a  sense,  but  at  the  same 
time  agree  within  certain  limits.  The  student  can  appreciate  these 
discrepancies  by  studying  analyses  of  milk  given  by  a  number  of 
authors.  Whereas  there  are  differences  in  proteids,  these  differences 
have  certain  limitations. 

Konig's  analysis,  as  modified  by  White  and  Ladd  gives  the  fol- 
lowing composition  of  human  milk  and  cows'  milk : 

Cow.  Human. 

Caseinogen 2.88  0.59 

Whey  proteids 0.53  1.25 

3^  T84 

The  casein  in  cows'  milk  comprises  five-sixths  of  the  proteids; 
in  human  milk,  two-sixths  of  the  total  amount.  We  should  bear 
this  important  fact  in  mind  in  reading  the  following  tables  compiled 
from  Camerer  and  Soldner,  showing  the  composition  of  human  milk : 

Ether  ext.  Milk-  „  „i  -j 

fat.  sugar.  Proteids. 

Colostrum 5.0  4.5  3.5 

Milk,  fifth  day 2.3  6.7  1.6 

Milk,  ninth  day 3.4  6.7  1.4 

Milk,  first  month 2.6  7.3  1.1 

Second  and  third  months 2.4  to  1.9  7.5  0.9 

Backhaus  gives  the  following  table  of  average  composition  (in 
100  parts)  of  human  milk: 

Water .-88.20 

Proteids    ....  .       |  0-75  casein. 

1  1.00  albumin  (whey  proteids). 

Fat 3.50 

Sugar 6.20 

Ash  ...        0.25 

On  comparing  these  figures  with  those  of  Konig,  White,   and 


Sugar. 

Fat. 

4.20-  7.60 

0.70-9.00 

5.90-  7.80 

2.70-4.60 

5.35-  7.95 

1.31-7.61 

5.20-10.90 

1.60-9.46 

92  .  NUTBITION  AND  INFANT  FEEDING. 

Ladd,  it  Avill  be  seen  that  White  and  Ladd  include  all  the  proteids 
exclusive  of  casein  under  the  name  of  whey  proteids.  The  whey 
proteids  are  principally  lactalbumin  and  lactoglobulin. 

The  above  analyses  tend  to  show  that  one  examination  of  any 
breast  milk  gives  but  incomplete  information  as  to  its  constant  quali- 
ties; it  will  only  tell  us  the  composition  of  that  one  specimen  of 
milk.  In  a  general  way  we  can  speak  of  averages,  and  these  we 
shall  try  to  elucidate  under  the  various  headings.  In  order  to  appre- 
ciate the  wide  variations  in  the  percentages  of  the  proteids,  sugar, 
and  fats  present  at  the  different  periods  of  lactation,  it  is  further 
necessary  to  study  the  following  analyses  of  leading  authorities : 

Proteids. 

Pfeiffer 1.049-3.04 

Johanessen  and  Wang  .  .  0.900-1.30 
V.  and  J.  Adiiance  ....  0.230-2.60 
Schlossmann 0.560-3.40 

Compared  with  human  milk,  the  following  table  of  animal  milk 
is  instructive  (Konig)  : 

Human.  Cow.  Goat.  Ass. 

Water 89.6  87.7  87.3  89.6 

Casein 1.4  3.0  3.0  0.7 

Albumin 0.6  0.4  0.5  16 

Fat 3.1  3.7  3.9  1.6 

Sugar 5.0  4.5  4.4  6.0 

Ash      0.3  0.7  0.8  0.5 

Proteids. — There  are  four  albuminous  bodies  or  proteids  in  hu- 
man milk.  The  most  important  is  the  casein,  which  is  in  a  class  by 
itself.  The  other  group  of  proteid  bodies  includes  the  soluble  albu- 
mins or  whey  proteids  (lactalbumin),  globulin,  and  opalisin.  The 
casein  of  human  milk  comprises  two-sixths  of  the  total  amount  of 
proteids ;  whereas  in  cows'  milk  it  comprises  five-sixths  of  the  pro- 
teids. This  is  an  exceedingly  important  distinction  between  the  two 
milks.  The  casein  of  human  milk  is,  according  to  reaction,  a  differ- 
ent casein  from  that  of  the  milk  of  the  lower  animals.  Szontagh  and 
Wrobelewski  contend  that  whereas  the  casein  of  human  milk  does  not 
yield  pseudonuclein  on  pepsin  digestion,  it  is  not  a  nucleo-albumin, 
and  hence  differs  widely  from  the  casein  of  cows'  milk.  Human 
milk,  as  stated,  is  not  only  poorer  in  casein  than  cows'  milk,  but  the 
casein  is  less  in  proportionate  combination  with  the  remaining  pro- 
teids and  lactalbumin.  This  in  part  explains  the  more  flocculent 
nature  of  the  casein  coagulum  in  human  milk. 

The  casein  of  human  milk  is  derived  from  the  protoplasm  of 
the  cells  of  the  mammary  gland.  It  is  set  free  from  the  cells  of 
the  mammary  gland  in  which  the  fat  is  formed.  In  addition  to  the 
proteids  human  milk  contains  lecithin,  0.58  per  cent.  (Burrow)  ; 
iron,  3.52  to  7.21  mg.  to  the  litre  (Jolles  and  Friedjung). 


PLATE  V 


FIG.  1 


FIG.  3 


FIG.  4 


Microscopic  Appearance   of  Woman's   Milk. 

Fig.  1, — Normal  milk,  showing  the  preponderance  of  medium-sized  fat-globules. 
Fig.  2. — Poor  milk.     Preponderance  of  large  fat-globules  and  a  paucity  of  fat. 
Fig.  3.— Poor  milk,  a  paucity  of  fat  and  an   almost    granular  state  of   the    fat- 
globules. 
Fig.  4.— Colostrum  of  later  pregnancy. 

Figs.   1,  2  and  3  from  Fleischman.     Fig.   4  from  Marfan. 


TRE  FOOD  OF  TEE  INFANT.  93 

Fats. — The  fat  of  human  milk  is  contained  in  the  so-called  fat- 
globules.  On  placing  a  drop  of  human  milk  under  the  microscope, 
the  fat-globule  is  seen  as  a  highly  refracting,  spherical  body.  The 
globule  varies  in  measurement  from  0.001  mm.  to  0.02  mm.  in 
diameter  (Plate  V.),  as  compared  to  0.0016  to  0.01  mm.  the  size 
of  the  fat-globule  of  cows'  milk.  It  is  therefore  larger  than  that 
of  cows'  milk.  The  fat  of  human  milk  is  a  yellowish-white  mass, 
when  separated  resembling  butter,  with  the  specific  gravity  of  0.966. 
It  melts  at  34°  C,  and  is  solid  at  20.2°  C.  It  contains  butyric, 
caproic,  capric,  myristic,  palmitic,  stearic,  and  oleic  acids.  It  is 
j)oor  in  volatile  fatty  acids.  The  non-volatile  fatty  acids  consist  of 
fully  50  per  cent,  oleic  acid,  while  the  palmitic  and  myristic  acids 
exist  in  greater  quantity  than  the  stearic  acid. 

In  addition  to  the  casein  and  fat  we  have  the  water,  89.6  per 
cent.  Moreover,  human  milk  contains  nucleon,  0.124  per  cent.; 
lecithin,  0.58  per  cent. ;  iron,  3.52  to  7.21  mg.  to  the  litre. 

If  milk  is  stained  with  carbol  thionine  or  methylene  blue  there 
are  seen,  as  in  the  colostrum,  crescent-shaped  bodies  which  are  adher- 
ent to  the  outer  border  of  the  fat-globule.  They  are  not  nucleolar 
or  remains  of  nuclei,  but  are  portions  of  the  mammary  epithelium 
which  have  adhered  to  the  milk-globule  at  the  time  of  its  expulsion 
from  the  cell  (Lourie). 

Mineral  Salts  in  the  Milk. — Human  milk  contains  a  number  of 
salts,  among  which  are  calcium  phosphates,  potassium,  magnesium, 
iron,  alum,  calcium  and  sodium  chlorides,  sodium  carbonate,  traces 
of  fluorine  and  silicium.  The  most  important  of  these  salts  are  the 
tribasic  calcium  phosphates,  part  of  which  are  held  in  solution,  an- 
other part  exists  in  a  colloid  state,  the  remaining  portion  being  in 
suspension,  and  is  seen  under  the  microscope  as  minute  dust-like 
particles  in  the  milk,  /4ooo  mm.  in  diameter  (Duclaux).  The  tri- 
basic calcium  phosphate  is  insoluble  in  water,  but  in  the  milk  is  held 
in  solution  by  the  presence  of  the  alkaline  citrates. 

Salts  in  the  milk.  Human  milk.       Cows'  milk  (Soldner). 

Natrium  chloride 1.35  0.962 

Calcium  chloride 0.70  0.870 

Calcium  phosphate 2.50  1.477 

Natrium  phosphate 0.40 

Magnesium  phosphate 0.50  0.336 

Carbonate  of  soda 

Fluorite  calcium trace. 

Potassium  citrate 0.495 

Magnesium  citrate 0.367 

Calcium  citmte      2.133 

Iron  phosphate 0.01 

Reaction. — The  reaction  of  human  milk  depends  on  the  presence 
of  the  contained  salts.    It  is  amphoteric,  alkaline  to  litmus  and  acid 


94  NUTRITION  AND  INFANT  FEEDING. 

to  plieuolphthalin.  The  actual  quantity  of  sodium  and  potassium 
varies,  the  sodium  being  more  abundant  than  the  potassium  at  the 
beginning  of  lactation  (De  Lange).  In  other  words,  the  reaction  of 
human  milk  is  amphoteric. 

Specific  Gravity. — The  specific  gravity  ranges  from  1.028  to 
1.034,  being  lower  in  poorly  nourished  women. 

Bacteria  in  the  Breast  Milk. — A  woman  in  good  health  will  show 
bacteria  in  the  breast  milk.  They  are  found  in  the  galactiferous 
ducts  of  the  breast  nipple.  After  expressing  the  first  drops  of  milk 
and  flushing  the  ducts,  it  is  found  that  the  after-coming  milk  is  free 
from  bacteria.  The  bacteria  found  in  the  breast  milk  belong  prin- 
cipally to  the  Staphylococcus  albus  class  but  the  Staphylococcus 
pyogenes  aureus  and  some  forms  of  Streptococcus  have  also  been 
found  by  Kohn  and  ISTeuman. 

These  bacteria  have  no  ill-effect  on  the  infant,  and  the  attempt  to 
trace  dj^speptic  disturbances  to  them  is  not  supported  by  clinical 
facts. 

Enzymes  and  Alexins  of  Human  Milk. — According  to  the  latest  in- 
vestigations, the  proteids  of  human  milk  contain  certain  derivatives 
of  the  living  cell.  I^ot  much  is  known  about  them  as  yet,  but  their 
presence  proves  beyond  a  doubt  that  human  milk  is  a  substance 
essentially  different  from  the  milk  of  other  animals.  Moreover,  their 
presence  in  the  milk  and  the  presence  of  other  substances  in  animal 
milk  proves  that  all  milk  is  a  living  product  and  not  a  dead  substance. 

The  enzymes  are  the  soluble  ferments  in  human  milk,  the  most 
important  of  which  is  the  so-called  amylase,  first  described  by 
Bechamp  and  subsequentl}^  by  Moro.  It  is  capable  of  converting 
starch  into  sugar  in  the  same  manner  as  does  the  secretion  of  the 
parotid  gland ;  in  other  words,  it  exerts  a  diastatic  action  on  starch. 
Amylase  is  not  found  either  in  cows'  or  sheep's  milk.  It  is  destroyed 
by  heat,  and  human  milk  heated  above  a  certain  temperature  loses 
its  amylolytic  properties.  This  ferment  is  present,  though  to  a  much 
less  degree,  in  dogs'  and  asses'  milk.  It  is  supposed  to  be  derived  from 
and  is  a  product  of  the  glandular  tissue  of  the  mammary  gland,  and 
is  not  primarily  present  in  the  blood.  The  reason  of  its  presence 
in  human  milk  is  not  quite  understood,  inasmuch  as  the  infant 
reared  exclusively  on  breast  milk  does  not  receive  any  starchy  sub- 
stances in  its  food. 

Marfan  isolated  another  ferment  in  the  milk,  called  lipase,  which 
is  capable  of  splitting  monobutyrin  into  butyric  acid  and  glycerin. 
This  lipase  is  present  to  a  slight  extent  in  cows'  milk.  Human 
milk  contains  also  a  ferment  capable  of  Sjilitting  salol  into  phenol 
and  salic,ylic  acid,  and  a  substance  capable  of  coagulating  fibrin, 
inasmuch  as  a  minnto  (inantitv  of  hnman  milk  added  to  hvdrocele 


THE  FOOD  OF  THE  INFANT.  95 

1 

fluid  causes  its  immediate  coagulation  (Moro  and  Hamburger).  This 
substance  is  not  present  in  cows'  or  goats'  milk.  Moreover,  human 
milk,  as  also  the  milk  of  animals,  possesses  certain  vital  specific 
properties.  Bordet,  Moro,  and  others  have  shown  that  if  human 
milk,  cows',  goats'  or  any  other  animal  milk  be  injected  into  the 
peritoneal  cavity  of  an  animal,  the  serum  of  that  animal  in  very 
high  dilutions  is  capable  of  coagulating  the  milk  of  the  animal 
whose  milk  was  injected  into  its  body. 

Human  milk  contains  so-called  alexins — that  is,  bactericidal  and 
globulicidal  substances — and  Moro  has  shown  that  the  serum  of  the 
blood  of  the  breast-fed  infant  is  more  bactericidal  than  the  serum  of 
the  blood  of  the  infant  fed  upon  cows'  milk. 

Amount  of  Breast  Milk  Consumed  by  the  Infant  in  Twenty-four  Hours. 
— Camerer  has  collated  and  analyzed  the  results  obtained  by  Ahlfeld, 
Pfeiifer,  Weigelin,  and  Hahner  as  to  the  quantity  of  breast  milk 
taken  daily  by  an  infant.  These  figures  were  obtained  by  weighing 
an  infant  from  the  earliest  period  before  and  after  nursing.  Camerer 
gives  us  the  following  table,  the  amounts  being  indicated  in  cubic 
centimetres : 


Day. 


1st.         ^        3d         4th.         oth.         6th,         7th.         10th.         14th. 
30         130       240        290         330         365         400         450  500 

Amount  of  Milk  Taken. 

Middle  2d  week.  4th  week.  7th  week.  10th  week.  20th  week 

Minimum.    .    .    210                 380  520                600  700 

Medium     ...    440                580  770                800  900 

Maximum     .    .    .540                810  1040               1170  1150 

The  amount  of  breast  milk  consumed  by  the  infant  at  each  nurs- 
ing must  vary  with  the  frequency  with  which  the  infant  is  placed  at 
the  breast.  If  the  infant  is  placed  at  the  breast  five  times  in  twenty- 
four  hours  the  mean  quantity  of  milk  taken  at  each  feeding  is 
quite  large  as  is  seen  by  consulting  Ahlfeld's  figures.  Thus  an 
infant  at  the  breast 

1  month  old  consumes •  .    .    .    .    104  ccm. 


2  months 

3 

4 

5 

6 

7 


163 
173 
212 
212 
214 
217 


These  figures  are  within  the  limits  of  stomach  capacities  given 
by  Pfaundler  and  in  excess  of  those  of  Fleischman,  Holt,  and  Eotch. 
If  the  infant  nurses  at  more  frequent  intervals  than  Ahlfeld's  baby. 


96  NUTBITION  AND  INFANT  FEEDING. 

the  quantity  of  milk  ingested  at  each  nursing  will  be  less  than  the 
above  figures. 

It  is  noteworthy  that  on  the  first  day  of  life  the  infant  observed 
by  Camerer  nursed  three  times,  and  seven  times  in  twenty-four 
hours  from  the  second  to  the  fourteenth  day.  Each  nursing  occupied 
a  mean  of  about  twenty  to  twenty-five  minutes.  These  data  are  of 
value  in  the  artificial  feeding  of  infants. 

The  quantity  of  milk  secreted  by  the  human  breast  may  increase 
up  to  the  ninth  week  of  lactation,  and  remain  stationary  from  this 
time  to  the  period  of  weaning ;  or  the  amount  of  milk  secreted  daily 
may  increase  from  the  earliest  period  to  that  of  weaning,  when  it  is 
at  its  height  (Czerny). 

Changes  in  the  Composition  of  Milk, — Daily  Changes. — ^Milk  may 
vary  in  composition  in  the  course  of  twenty-four  hours  in  the  same 
nurse,  both  in  the  total  amount  of  proteids  and  fats,  to  the  extent  of  1 
per  cent,  or  more.  Schlichter  has  found  that  the  changes  occur  at 
various  times  in  the  day. 

The  composition  of  the  milk  in  the  nursing  woman  at  different 
hours  of  the  day  may  be  seen  in  the  following  table  by  Schlichter : 

Nurse  A.  Casein.  Fat.  Proteids.  Sugar. 

Morning 1.10  0.80  1.69  7.11 

Noon 1.10  1.88  2.16  6.92 

Night ....  3.16  1.95  6.83 

Nurse  B. 

Morning 0.55  3.77  1.19  5.37 

Noon 0.77  3.90  1.91  6.15 

Night 0.71  3.73  1.26  6.19 

Nurse  C. 

Morning 0.55  3.61  0.19  6.18 

Noon 0.83  4.21  1.08  6.24 

Night 0.41  3.60  1.16  6.47 

Gregor  has  shown  that  the  variation  in  the  color  and  consistence 
of  the  stools  of  infants  can  be  accounted  for  by  the  variation  in  the 
gross  amount  of  fats  in  human  milk  at  different  times  of  the  day 
and  from  day  to  day. 

Influence  of  Foods  on  Breast  Milk.^ — A  diet  rich  in  nitrogenous 
substances  increases  the  quantity  of  the  milk  and  the  percentage  of 
fats  and  proteids.  A  diet  rich  in  fat  may  increase  the  percentage 
of  fat  in  the  milk.  On  the  other  hand,  it  is  not  always  possible 
to  increase  the  casein  in  the  milk  l)y  means  of  diet  if  the  milk  is  poor 
in  this  constituent  (Konig).  Starvation  lessens  the  quantity  of  the 
milk  and  the  proportion  of  the  casein  to  the  other  proteid  bodies  in 
the  milk  in  the  same  manner  as  does  a  poor  dietary  (Decaisne).  If 
we  enlarge  the  diet  we  improve  the  milk.  Beer  and  malt  liquors 
increase  the  quantity  of  the  milk  and  the  percentage  of  its  fat-con- 
stituents (Konig). 


TRE  FOOD  OF  THE  INFANT.  97 

In  trying  to  improve  tlie  milk  of  the  human  breast  we  should 
not  resort  to  too  much  experimentation,  for  a  good  milk  will  some- 
times be  made  unfit  for  the  infant  by  placing  the  nurse  or  the 
mother  on  a  diet  to  which  she  is  unaccustomed.  On  the  other  hand, 
I  have  seen  the  milk  retain  its  colostrum  characteristics  through  the 
fact  that  the  mother  did  not  follow  out  the  dietary  to  which  she  was 
accustomed  previous  to  delivery  and  did  not  take  her  usual  exer- 
cise. Women  accustomed  to  a  wholesome,  moderate  dietary  will, 
if  fed  liberally  with  fats  and  carbohydrates,  secrete  a  milk  rich  in 
fats  and  poor  in  proteids ;  such  a  milk  will  at  once  disagree  with  the 
infant  (Konig"). 

If  a  nurse  has  been  on  an  insufficient  diet,  the  diet  should  be 
increased  in  a  general  way.  She  should  have  a  moderate  allowance 
of  meat,  partake  sparingly  or  not  at  all  of  tea,  coffee  or  beer,  and  have 
sufficient  exercise.  If  with  these  changed  conditions  the  milk  does  not 
improve  both  in  quantity  or  quality  we  should  not  hesitate  to  replace 
the  nurse  by  another ;  or  if  the  mother  is  nursing  the  infant,  to  aid  the 
breast  with  artificial  food.  This  is  preferable  if  the  mother  is  nursing 
to  taking  the  infant  away  from  the  breast. 

Drugs  and  Foreign  Substances  in  the  Milk. — Iodine  and  salicylic 
acid  may  pass  from  the  blood  into  the  milk  of  the  human  breast. 
Iodine  may  even  cause  iodism  in  the  nursing  infant  when  the  nurse  is 
taking  any  appreciable  amount  of  iodide  of  potassium  (Koplik). 
Iodine  is  eliminated  in  combination  with  the  casein  of  the  milk. 
As  to  the  appearance  of  other  substances,  such  as  drugs,  in  the 
human  milk  if  taken  in  medicinal  doses  by  the  mother  or  nurse  much 
is  to  be  learned,  for  very  little  is  actually  known. 

Opium  is  not  eliminated  if  taken  in  ordinary  doses,  though  atro- 
pine may,  if  taken  by  the  nurse,  be  eliminated  in  the  milk  and  cause 
dilatation  of  the  pupil  in  the  infant.  Alcohol  taken  in  limited 
amounts,  as  is  customary  at  the  table,  is  not  found  as  alcohol  in 
breast  milk ;  but  if  larger  quantities  are  taken,  from  two-tenths  to 
six-tenths  of  1  per  cent,  of  alcohol  may  be  found  in  the  milk. 

Passage  of  Bacteria  of  the  Infectious  Diseases  Into  the  Breast  Milk. 
— The  extent  to  which  bacteria  of  the  various  diseases  may  pass  into 
the  milk  of  the  infected  woman  is  still  a  matter  of  question.  Under 
the  heading,  Contra-indications  Against  jN'ursing  the  Infant,  this 
matter  has  been  discussed  in  part.  It  has  been  proved  that  the 
toxins,  antitoxins,  and  agglutinins  of  the  infectious  diseases,  such  as 
typhoid  fever  and  diphtheria,  may  pass  into  the  milk  of  the  nursing 
woman  suffering  from  these  diseases.  The  bacillary  infection  of  the 
milk,  however,  is  quite  a  different  matter,  concerning  which  much  is 
to  be  learned.  In  local  tuberculous  infection  of  the  mammae  it  can 
well  be  understood  that  bacilli  may  gain  direct  access  to  the  milk 

7 


98  -  NUTRITION  AND  INFANT  FEEDING. 

through  infections  foci  of  the  galactiferons  dncts.  It  is  still  qnestioii- 
able  whether  milk  from  a  gland  free  from  local  foci,  thongh  coming 
from  a  woman  affected  with  tuberculosis,  mav  contain  tubercle  bacilli. 
In  typhoid  fever  and  diphtheria  the  bacilli  may  appear  in  the  milk  of 
a  woman  suffering  from  severe  systemic  invasion  of  the  bacilli  of 
either  of  these  diseases,  but,  as  a  rule,  this  is  not  the  case.  In  pneu- 
monia we  can  scarcely  apply  to  the  human  subject  the  results  obtained 
in  the  lower  animals,  for  in  the  former  the  disease  is  rarely  an  in- 
vasion of  the  blood  to  the  extent  seen  in  the  lower  animals.  Thus, 
cases  such  as  those  published  by  Bozzolo,  in  which  pneumococci  were 
found  in  the  milk  of  a  woman  suffering  from  severe  pneumonia  and 
endocarditis,  are  exceptional. 

Toxins,  Antitoxins,  and  Agglutinins. — Tetanus  toxins  and  antitoxins 
may  pass  into  breast  milk,  and  in  certain  animals,  such  as  mice,  this 
milk  may  confer  immunity  on  the  nursling  (Ehrlich,  Brieger). 

Diphtheria  toxin  and  antitoxin  may  be  eliminated  in  the  breast 
milk.  Ehrlich  and  Wassermann  found  that  goats  immunized  against 
diphtheria  could  confer  this  immunity  through  the  milk.  Roux  and 
Martin  confirmed  this  observation  in  the  cow.  It  has  also  been  proved 
that  the  breast  milk  of  women  convalescent  from  typhoid  fever  pos- 
sessed agglutinating  properties  on  the  Eberth  bacillus  similar  to  that 
of  the  blood  (Achard,  Bensaude),  and  that  this  agglutinating  prop- 
erty could  be  transferred  to  the  blood  of  the  infant  nursing  this  milk 
(Landouzy,  Griffon,  and  Casteigne).  In  passing  from  the  blood  into 
the  breast  milk  the  agglutinating  substance  is  much  weakened,  like- 
wise more  so  when  transferred  from  the  milk  to  the  blood  of  the 
nursing  infant. 

The  above  facts  would  seem  to  indicate  that  the  question  as  to 
whether  the  breast  milk  of  a  mother  or  nurse  suffering  from  any 
disease  is  fit  for  the  nursling  is  not  an  indifferent  one.  The  passage 
of  toxins,  antitoxins,  and  agglutinins  into  the  milk  should,  with  reser- 
vations mentioned  elsewhere,  forbid  the  use  of  any  breast  milk  coming 
from  a  mother  or  nurse  the  victim  of  active  acute  or  chronic  disease. 

Menstruation, — The  effect  of  the  function  of  menstruation  on 
breast  milk  is  still  a  matter  of  discussion.  Rotch  has  found  some 
variations  at  this  period,  not  only  in  the  percentage  of  the  fat,  but  in 
the  proteids,  from  that  which  existed  before  menstruation.  Other 
authors  think  the  greatest  variations  will  be  found  in  the  fats  (Ben- 
dix).  I  am  inclined,  however,  from  my  own  experience  to  believe 
that  variations  in  breast  milk  during  menstruation  are  exceptional, 
for  the  great  majority  of  infants  do  not  show  at  this  time  any  dis- 
turbances of  the  functions  of  the  gut.  An  exception  to  this  may  prob- 
ably be  the  first  menstruation  of  lactation.  Infants  at  this  time  may 
have  green  movements  and  slight  colicky  ]iains  which  persist  until 


THE  FOOD  OF  TEE  INFANT.  99 

menstruation  is  established  in  the  mother,  when  all  functional  disturb- 
ances of  the  gut  disappear  and  the  children  do  not  seem  to  be  dis- 
turbed by  the  recurrence  of  the  function.  In  fact,  if  we  study  the 
tables  of  the  analyses  made  before  and  during  menstruation  and  sub- 
sequent to  this  period  we  shall  see  that  the  variations  are  no  greater 
than  those  which  occur  from  day  to  day  when  menstruation  is 
absent. 

Pregnancy. — The  question  is  frequently  asked,  ''  Has  pregnancy 
any  effect  on  the  quality  or  quantity  of  the  milk,  and  may  an  infant 
nurse  the  breast  of  a  pregnant  woman  ? "  Having  conducted  a 
very  large  dispensary  class  in  diseases  of  infancy  and  childhood  for 
fifteen  years,  I  not  infrequently  saw  infants  nursed  at  the  breast  of 
pregnant  mothers.  Such  infants  did  not  seem  to  suffer ;  some  of 
them,  in  fact,  being  beautiful  babies.  Examination  of  these  mothers 
showed  them  to  be  pregnant  from  four  to;  six  months.  The  milk 
secretion  was  not  markedly  changed  in  amount.  This  corresponds 
to  what  has  been  established  by  Poirier,  who  found  that  of  100 
pregnant  mothers  who  nursed  their  infants,  72  infants  showed  no 
change  in  their  general  well-being,  while  20  showed  disturbances 
necessitating  immediate  weaning.  Eight  infants  showed  slight  intes- 
tinal disturbances.  The  question  may  be  justly  asked  whether  a;  like 
proportion  of  cases  might  not  be  met  with  necessitating  weaiiing 
among  mothers  not  pregnant  and  nursing  their  babies.  Pregnancy 
may  diminish  the  amount  of  milk,  but  in  the  majority  of  cases  no 
change  occurs.  It  is  just,  however,  unless  extraordinary  indications 
to  the  contrary  exist,  that  a  mother  should  not  be  asked  to  nurse  her 
baby  while  pregnant  with  another.  Such  an  infant  should  be  weaned 
from  the  breast. 

Methods  of  Analysis  of  Human  Milk. — In  the  section  treating 
of  the  examination  of  breast  milk  it  was  shown  that  with  experience 
it  is  possible  to  decide  in  a  general  way  as  to  the  quality  of  the  milk 
without  chemical  analysis.  Emergencies,  however,  arise  which  may 
necessitate  more  careful  examination  of  the  milk  in  order  to  account 
for  some  disturbing  symptom  in  the  infant.  After  thriving  for  a  few 
weeks  the  infant  may,  without  apparent  cause,  cease  to  gain  in 
weight,  or  the  movements  may  be  abnormal,  or  there  may  be  colic. 
Under  these  conditions  it  is  certainly  an  advantage  to  be  able  to  de- 
termine the  composition  of  the  milk,  since  a  chemist  is  not  always  at 
hand.  Conrad,  a  physician  in  Bern,  has  devised  some  instruments 
which  are  easily  manipulated  and  are  within  the  reach  of  every 
physician.  His  article,  published  in  1880,  is  still  unsurpassed  in 
clearness  of  detail.  The  milk  to  be  used  in  all  analyses  is  that  ob- 
tained in  the  mid-period  of  nursing. 

Specific  Gravity. — To  ascertain  the   specific  gravity,   Conrad   re- 


100 


NUTBITIOX  AND  IXFANT  FEEDING. 


Fig. 


M 


-^^^-  ^^-  duced  the  size  of  Qiievenne's  lacto- 

densimeter  so  that  it  could  be  uti- 
lized for  taking  the  specific  gravity 
of  small  quantities  of  mother's  milk 
(Fig.  16),  The  specific  gravity  is 
taken  at  15°  C.  The  scale  runs 
from  1020  to  1050. 

Fat.^ — Conrad  estimated  the  fat 
by  first  calculating  the  cream  layer. 
This  he  determined  by  means  of  a 
gTaduated  glass  cylinder  devised  by 
Bouchardat,  Quevenne,  and  Cheva- 
lier. This  cylinder  he  reduced  in 
size.  The  method  is  so  unreliable 
that  it  is  merely  mentioned  in  pass- 

Of  greater  reliability  is  the 
]\Iarchand  tube,  reduced  in  size  by 
Conrad.  The  set  consists  of  two 
of  these  tubes.  Each  tube  analyzes 
5  c.c.  of  milk  (Fig.  15). 

Five  c.c.  of  milk  are  poured  into 
the  tube,  and  then  5  c.c.  of  ether. 
These  are  well  shaken  after  a  drop 
of  ofiicinal  caustic  soda  solution  has 
been  added.  Absolute  alcohol  is 
then  added  up  to  the  A  mark.  The 
whole  is  again  shaken  and  placed  in 
water  at  35 '^^  to  40"  C.  for  ten  or 
fifteen  minutes.  The  fat  separates 
above,  and  is  read  off.  A  percentage 
table  accompanies  the  instrument. 
This  instrument  is  not  accurate. 
There  is  a  variation  of  from  0.2  to 
0.5  per  cent,  or  more.  Two  analy- 
ses are  made  at  the  same  time  for 
the  sake  of  accuracy;  hence  the  two 
tubes. 

Lewi's  Metliod. — More  accurate 
than  Conrad's  is  the  method  worked 
out  in  mv  clinic  by  Lewi.  This  is 
really  an  adaptation  to  breast  milk 
of  the  Babcock  sulphuric  acid 
method,  as  modified  l)y  Leifman  and  Beam. 

The   apparatus  needed   comprises   a   reduced   Babcock  bottle,   a 


Conruds  lactobutyr- 
ometer. 


Conrad's  lactoden- 
simeter. 


THE  FOOD  OF  THE  INFANT. 


101 


pipette  for  measuring  the  milk  and  acid,  and  a  smaller  1  c.c.  pipette 
accurately  divided  into  cubic     ^k 


(see 


Figs. 


ir. 


17. 


3.93 


Fig.  18. 


Fifi.  19. 


^4 


£^3 


millimetres 
18,  19). 

The  pipette  is  filled  to 
-  the  meniscus  (this  represents 
2.92  c.c.  of  mother's  milk) 
and  introduced  carefully  into 
the  body  of  the  bottle,  so  that 
the  long  thin  pipette  comes 
down  into  the  body  of  the  bot- 
tle. The  pipette  is  cleansed, 
and  refilled  to  the  meniscus 
with  chemically  pure  sul- 
phuric acid ;  the  pipette  is  in- 
troduced as  before.  This  pre- 
caution is  taken  in  inserting 
the  pipette  so  that  at  this 
stage  no  ebullition  shall  occur 
in  the  neck  of  the  bottle,  and 
so  invalidate  the  result. 
]^ext,  fill  the  1  c.c,  pipette 
up  to  the  sixth  marking  with 
a  mixture  of  equal  parts  cf 
fusel  oil  and  concentrated 
hydrochloric  acid ;  add  this 
to  the  milk  and  sulphuric 
acid  and  fill  the  bottle  with 
equal  parts  of  sulphuric  acid 
and  water.  The  bottle  is 
placed  in  an  aluminum  re- 
ceiver and  adjusted  to  the 
centrifuge.  The  specimens 
are  revolved  one  and  a  half 
to  two  minutes,  and  the  read- 
ing is  then  taken. 

This  method,  if  carefully 
carried  out,  gives  very  little 
error,  and  is  practically  equal 
to  the  Soxhlet  quantitative 
fat  estimation.  It  can  be  ap- 
plied to  cows'  as  well  as  to 
human  milk. 

The  following  table  shows  the  error  in  the  various  methods  as 
compared  with  accurate  chemical  determination: 


^0 


— J^ 


Instruments   employed  in  the  estimation   of 
fat  in  milli.     Lewi's  method. 


102 


NUTRITION  AND  INFANT  FEEDING. 


Soxhlet 
(chemical). 

Reduced 
centrifuge. 

Marchand. 

Feser. 

Specimen 

1 4.4  per  cent. 

4.4  per  cent. 

3.48  per  cent. 

5.00  per  cent. 

II.   . 

i  2.4 

2.3 

2.56 

2.37         " 

III. 

1  1.1         « 

1.1 

1.44        " 

1.25 

IV. 

1  3.9 

3.8 

3.17 

3.25 

VI. 

:  4.6 

4.7 

2.35 

3.80 

VII. 

!  2.3 

2.3 

3.99 

2.20         " 

A^II. 

!  4.4 

4.2         " 

3.68 

4.20         " 

VIII. 

,  4.7         " 

4.6 

3.60         " 

The  Proteids. — To  possess  clinical  value  in  the  determination  of 
the  proteids,  a  method  must  differentiate  between  the  amount  of 
casein  and  that  of  the  other  proteids,  such  as  lactalbumin  and  lacto- 
globulin.  This  is  possible  only  by  careful  and  exhaustive  quanti- 
tative chemical  analyses.  The  methods  at  our  disposal  which  are 
practicable  in  the  physician's  office  determine  only  the  gross  proteids. 
The  gross  proteids  may  be  normal  in  amount,  and  the  casein  or 
caseinogen  be  deficient.  Such  milk  would  not  be  nutritious.  This 
was  demonstrated  years  ago  in  sick  and  starving  women  (Decaisne). 

The  following  is  the  method  of  Woodward  for  determining  the 
total  proteids:   Two  ''milk  burettes"    (Fig.   20),   each  containing 

Fig.  20. 


Milk  burette  of  Woodward. 


5  c.c.  of  milk,  are  allowed  to  stand  overnight  in  a  warm  place  (100° 
F.,  38°  C).  Thej  are  then  cooled.  The  milk  is  drawn  off  into 
two  Eshbach  tubes,  and  10  c.c.  of  the  Esbach  solution  added.  The 
tubes  are  then  shaken,  put  into  a  centrifuge,  and  rotated  until  the 
reading  is  constant.  This  method  was  perfected  in  the  Pepper 
Laboratory,  Philadelphia.  The  author  has  utilized  this  method,  and 
found  it  satisfactory. 

Cows'  Milk. — Composition. — Of  700  analyses,  Konig  gives  the 
following  as  the  average  composition  of  cows'  milk  for  100  parts : 
Water,  87.2;  casein,  2.88;  albumin  (lactalbumin),  0.51;  fat,  3.68; 
sugar,  4.90.  Cows'  milk  has  a  .specific  gravity  of  from  1.028  to 
1.034.  It  is  amphoteric  in  reaction,  but  is  relatively  more  acid  than 
human  milk.  Fresh  cows'  milk  does  not  coagulate  on  boiling,  but  heat 
causes  a  skin  of  casein  and  lime  salts  to  form  on  the  surface  of  the 
milk.    Tf  allowed  to  stand  at  the  temperature  of  the  room,  lactic  acid 


TEE  FOOD  OF  TEE  INFANT.  103 

is  formed  in  cows'  milk  as  a  result  of  bacterial  growth  and  splitting 
of  the  milk  sugar  and  coagulation  or  curdling  of  the  casein  occurs 
when  the  milk  is  heated ;  after  a  while,  an  excess  of  acid  being  formed, 
spontaneous  separation  of  the  casein  will  occur. 

Fat. — Fat  is  contained  in  cows'  milk,  as  in  human  milk,  in  the 
form  of  fat-globules,  which  are  held  in  suspension  in  the  serous  part 
of  the  milk  by  an  envelope  of  albumin.  There  is  no  doubt  that  the 
milk-globules  contain  all  the  fat  of  the  milk.  The  fat-globules  are 
smaller  than  those  of  human  milk.  It  is  uncertain  whether  the  fat- 
globules  contain  any  protein  substances. 

Proteids. — The  casein  of  cows'  milk  is  a  nucleo-albumin,  con- 
tains phosphorus  and  coagulates  when  heated,  as  also  by  the  addition 
of  acids  and  rennet.  The  amount  of  casein  in  cows'  milk  is  not 
only  relatively  but  absolutely  greater  than  in  human  milk ;  and  in 
describing  human  milk  it  was  stated  that  the  casein  forms  five- 
sixths  of  the  total  proteids  in  the  cows'  milk ;  whereas  in  human 
milk  the  casein  forms  two-sixths  of  the  total  proteids.  This  one 
fact  is  of  far-reaching  importance. 

Simple  dilutions  of  cows'  milk  still  leave  it  with  a  greater  propor- 
tion of  casein,  as  compared  to  the  other  proteids  in  the  milk,  than 
that  which  exists  in  human  milk.  Though  we  may  dilute  cows' 
milk  so  as  to  reduce  the  proteids  to  the  relative  proportion  in  which 
they  exist  in  human  milk,  we  cannot  do  this  without  at  the  same  time 
reducing  its  nutritive  value ;  that  is,  we  fail  to  get  the  quantity  of 
digestible  proteids  in  the  milk,  although  the  proteids  may  exist  in  the 
same  proportion  in  our  mixture.  In  other  words,  the  proteids  of  the 
cows'  milk  are  not  so  completely  assimilated  by  the  infant  as  are  those 
of  human  milk.  Again,  the  casein  of  cows'  milk  is  precipitated  or 
coagulates  very  early  with  the  aid  of  acid  and  salts ;  that  of  human 
milk  quite  late  or  not  at  all.  In  the  human  stomach,  therefore,  cows' 
milk  will  not  take  up  as  much  acid  of  the  gastric  juice  without  coagu- 
lating as  will  human  milk  and  the  coagula  occur  in  large  masses.  We 
can  readily  see  in  this  another  disadvantage  in  the  use  of  cows'  milk 
as  an  infant  food.  Human  milk,  on  the  other  hand,  takes  up  a  large 
amount  of  the  acid  of  the  gastric  juice  and  coagulates  in  very  fine 
flocculi.  This  finer  mode  of  coagulation  accounts  partly  for  the  more 
complete  assimilation  of  human  milk  by  the  infant. 

It  was  formerly  thought  that  the  casein  of  human  and  cows' 
milk  were  chemically  identical.  Later  study,  however,  shows  that 
the  casein  of  human  milk,  in  contradistinction  to  that  of  cows'  milk, 
is  not  a  nucleo-albumin  (Szontagh).  Human  milk  is  richer  in 
nucleon  and  lecithin  than  cows'  milk  and  contains  more  combined 
phosphorus  than  cows'  milk  in  the  nucleon.  It  can  be  seen  from 
this  that  the  contention  of  Hoppe-Seyler,  Hammarsten,  and  Wrobe- 


104  '  NUTRITION  AND  INFANT  FEEDING. 

lewski,  tiiat  the  two  caseins  are  essentially  different,  is  well  founded. 
ISTot  only  is  the  casein  of  cows'  milk  a  substance  sui  generis,  but  its 
digestion  in  the  intestine  of  the  infant  is  accomplished  with  great  loss. 
Moreover,  it  has  been  shown  that  the  salts  of  cows'  milk,  especially 
those  of  lime  and  potassium,  are  not  well  assimilated  by  the  infant 
gut,  fully  34  per  cent,  of  these  salts  being  excreted  by  the  put; 
whereas  only  10  per  cent,  of  these  salts  are  found  in  the  fseces  of  the 
infant  fed  at  the  breast. 

These  facts  are  of  great  importance  in  comparing  the  two  modes  of 
feeding  infants — that  of  the  breast  and  the  bottle.  The  prevalence 
of  bone  disturbances  of  the  severer  type  in  artificially  fed  infants  is 
thus  partly  explained  by  the  loss  of  the  salts  of  lime  and  potassium, 
these  being  important  to  bone  nutrition  and  growth.  The  increase 
of  weight  in  artificially  fed  infants  also  gives  us  an  insight  into  the 
physiological  processes  in  such  infants.  The  quantity  of  milk,  as 
before  stated,  necessary  to  maintain  nutrition  is  greater  in  the  case 
of  the  bottle-fed  infant  than  in  that  fed  on  the  breast.  There  is  always 
a  danger  of  overfeeding  an  infant  which  is  bottle-fed.  The  increase 
of  weight  is  not  as  regular  in  the  bottle-fed  infant  as  it  is  in  the 
breast-fed  infant. 

The  following  will  show  at  a  glance  the  differences  in  the  assimila- 
tion of  the  various  elements  of  cows'  milk  as  compared  to  human 
milk  by  the  infant  gut  (Uffelmann)  : 

Cows'  Milk  Human  Milk. 

Proteids 98.7  per  cent.  99.5  per  cent. 

Fats 93.5       "  97.5        " 

Salts 66.2       "  90.0 

Sugar 100.0        "  100.0        " 

Ash 92.0       "  97.0        " 

According  to  Forster,  an  infant  four  months  of  age  taking  1215 
c.c.  of  cows'  milk  excreted  three-fourths  of  the  lime  salts  in  the  fseces. 

Bacteria  in  Cows'  Milk. — Pasteurization;  Sterilization.- — By  in- 
sisting on  strict  cleanliness  of  the  cows'  udder,  the  hands  of  the 
milkman,  and  the  utensil  in  which  the  milk  is  collected,  it  is  pos- 
sible to  obtain  a  milk  tolerably  free  from  bacteria.  In  commerce, 
however,  this  is  manifestly  impracticable.  Milk  collected  with  the 
greatest  care  contains  bacteria,  and  if  these  appear  to  the  extent  of 
only  9000  to  the  cubic  centimetre  at  the  time  of  milking,  enough 
will  have  developed  under  favorable  conditions  to  cause  such  an 
increase  within  twenty-four  hours  at  an  ordinary  temperature  as  to 
bring  this  number  up  to  5,600,000  to  the  cubic  centimetre  (Miquel). 
Soxhlet  has  shown  that  in  order  to  inhibit  the  growth  of  these  bac- 
teria in  the  milk,  it  must  be  kept  at  a  very  low  temperature,  and  in 
summer  weather  practically  in  contact  with  ice. 


THE  FOOD  OF  TEE  INFANT.  105 

The  most  important  bacteria  fomicl  in  milk  are  the  Bacterium 
lactis  aerogenes,  the  Bacillus  mesentericus  vulgatus  (the  potato  ba- 
cillus), and  the  Bacillus  subtilis.  Cows'  milk  may  contain  also 
streptococci  which  come  from  the  udder  of  the  animal,  and  any 
pathogenic  bacteria,  such  as  the  pneumococcus,  typhoid  bacillus, 
diphtheria  bacillus,  the  germs  of  scarlet  fever,  measles,  or  tubercu- 
losis, cows'  milk  being  an  excellent  culture  medium  for  the  growth 
of  germs  of  all  infectious  disease. 

The  habitat  of  the  bacteria  of  cows'  milk  is  first  the  teat  of  the 
udder.  The  milk  ducts  in  the  teats  are  of  considerable  size  and 
residual  milk  decomposes  in  them.  The  entrance  of  bacteria  into 
these  ducts,  such  as  the  Bacterium  lactis  aerogenes,  the  hay  bacillus, 
the  potato  bacillus  (Bacillus  mesentericus  vulgatus),  is  favored  by 
the  habits  of  the  animal  and  uncleanliness  in  the  stalls  in  which  the 
animal  is  kept.  Uncleanly  utensils  in  which  the  milk  is  collected 
are  a  source  of  contamination. 

Infected  Cows'  Milk  as  a  Cause  of  Epidemics,- — Typhoid  Fever. — 
Cows'  milk  is  unquestionably  an  excellent  medium  for  the  growth 
of  bacteria  and  is  most  readily  infected ;  thus,  epidemics  of  typhoid 
fever  have  been  traced  to  infected  milk.  Such  milk  becomes  infected 
either  in  the  dairy,  where  the  fever  may  be  prevalent  among  the  dairy- 
men, or  through  dairy  utensils  which  have  been  cleansed  with  in- 
fected water. 

Dysentery. — Dysentery  may  be  caused  by  drinking  infected  milk 
(Klein). 

Diphtheria. — The  Klebs-Loffler  bacillus  grows  quite  well  in  cows' 
milk,  which  may  consequently  be  the  means  of  readily  spreading  the 
disease;  thus,  school  epidemics  have  been  traced  to  infected  milk. 

Scarlet  Fever. — -Scarlet  fever  has  been  conveyed  by  cows'  milk 
infected  by  those  contaminated  with  the  disease  (Kober,  Freeman). 

Cholera  Asiatica. — Cholera  Asiatica  may  be  conveyed  through 
milk  diluted  with  infected  water  or  milk  handled  by  a  cholera- 
infected  individual. 

Tuberculosis. — It  is  not  the  place  here  to  discuss  the  transmission 
of  tuberculosis  to  the  human  subject  by  means  of  the  milk  of  a 
tuberculous  cow.  This  matter  is  secondary  to  the  more  immediate 
question  as  to  the  prevalence  of  tuberculosis  in  the  infant  and  child 
as  a  result  of  the  ingestion  of  infected  cows'  milk.  That  this  mode 
of  acquiring  tuberculosis  is  exceedingly  rare  will  be  acceded  to  by 
most  observers,  and  published  epidemics  or  isolated  cases  of  tuber- 
culosis in  children,  caused  by  infected  cows'  milk,  lack  the  evidences 
of  absolute  certainty  as  to  etiology. 

Aside  from  tuberculosis,  it  is  generally  granted  that  suppurative 
disease  of  the  udder  of  the  cow  may  cause  serious  digestive  disturb- 


106  '  NUTEITION  AND  INFANT  FEEDING. 

ances  in  the  infant  by  infecting  the  milk.  In  fact,  certain  forms 
of  stomatitis  are  traced  by  some  (Forcheimer)  to  snch  a  source. 

Milk  Acidity. — If  milk  is  not  cooled  immediately  after  milking, 
and  kept  cool,  it  soon  shows  a  marked  increase  in  acid  reaction. 
This  is  due  to  the  growth  of  the  Bacterium  lactis  aerogenes,  which 
not  only  turns  the  milk  acid,  but  in  doing  so  produces  toxins  which 
are  of  considerable  danger  when  introduced  into  the  stomach  and 
gut  of  the  nursing  infant.  Without  entering  further  into  details, 
we  may  say  that  cows'  milk  intended  for  infant-feeding  should  be 
obtained  from  a  herd  of  healthy  animals,  preferably  of  the  Holstein 
type.  Mixed  milk  is  to  be  preferred  to  the  milk  from  one  cow,  for 
the  reason  that  any  infectious  element  introduced  into  the  milk  coming 
from  a  large  herd  of  animals  is  so  diluted  as  to  be  less  dangerous  to 
the  individual  infant  than  the  milk  containing  infectious  matter 
coming  in  a  concentrated  form  from  one  animal. 

The  milk  should  be  carefully  collected  in  utensils  which  have 
been  thoroughly  cleansed  and  sterilized  with  steam.  The  infant 
should  obtain  the  milk  as  soon  as  possible  after  the  milking;  cer- 
tainly within  twenty-four  hours.  Having  been  modified  and  put 
up  for  the  infant's  use,  the  food  should  be  presented  to  the  infant  in 
divided  portions,  each  of  which  is  sufficient  for  a  nursing. 

In  large  cities,  where  the  milk  does  not  come  direct  from  the 
dairy  to  the  infant,  it  is  still  thought  advisable  to  subject  the  milk 
to  various  forms  of  sterilization  or  heating,  in  order  that  the  con- 
tained bacteria  may,  for  the  most  part,  be  destroyed,  and  that  it 
may  remain  fit  for  feeding  the  infant  for  fully  twenty-four  hours. 
In  places  where  the  milk  can  be  obtained  direct  from  the  dairy,  and 
where  we  are  certain  that  the  collection  of  the  milk  has  been  carried 
out  with  care,  we  may  do  away  with  the  heating  process,  especially  in 
the  winter  time.  In  the  summer,  however,  some  form  of  sterilization 
is  necessary. 

Under  the  term  sterilization  the  author  includes  both  Pasteuriza- 
tion and  sterilization. 

Pasteurization. — Pasteurization  is  to-day  the  process  most  in  vogue 
for  the  preservation  of  infant  food,  and  also  to  destroy,  for  the  most 
part,  any  deleterious  bacteria  contained  in  the  milk.  It  was  first  per- 
fected by  Pasteur,  and  therefore  bears  his  name.  The  milk  is  sub- 
jected, in  a  suitable  apparatus,  to  a  temperature  of  65°  C.  (149°  F.) 
for  a  variable  length  of  time,  generally  half  an  hour,  and  then  rapidly 
cooled  to  SO'^  C.  (68°  F.).  The  most  practical  apparatus  for  this 
purpose  was  devised  by  Freeman,  and  is  sold  in  the  shops  as  the 
Freeman  Pasteurizer  (Fig.  21).  If  properly  carried  out  with  this 
apparatus,  the  method  destroys  all  pathogenic  germs  which  may  be 
present  in  the  milk,  and  also  a  large  percentage  of  the  other  bacteria 


TRE  FOOD  OF  THE  INFANT. 


107 


of  the  milk,  including  most  of  the  Bacterium  lactis  aerogenes,  but 
does  not  destroy  any  sporulated  bacteria,  such  as  the  Bacillus  mesen- 
tericus  vulgatus. 

Sterilization. — Sterilization  is  the  process  of  heating  milk  to  212° 
F.,  or  100°  C.  This  may  be  done  by  means  of  the  Arnold  Steam 
Sterilizer  (Fig.  23),  or  by  simply  placing  the  milk  in  properly  corked 
bottles  in  boiling  water.  As  a  rule,  the  milk  is  heated  for  twenty 
minutes,  when  it  is  considered  sterilized.  The  milk  should  then  be 
rapidly  cooled,  as  in  the  process  of  Pasteurization,  for  by  this  process 
the  fat  of  the  milk  will  not  separate.  Sterilization  is  best  performed 
by  the  above  processes,  but  the  ordinary  sterilizers  will  not  render  the 


Fig.  21. 


Fig.  22. 


Fig.  23. 


Freeman  Pasteurizer 


Arnold  Steam  Sterilizer. 


milk  absolutely  sterile.  It  will  not  destroy  any  sporulated  bacteria, 
but  will  destroy  the  Bacterivim  lactis  aerogenes  and  all  pathogenic 
germs.  Milk  which  contains  sporulated  bacteria,  such  as  the  potato 
bacillus  (Bacillus  mesentericus  vulgatus),  may  after  a  short  time 
undergo  a  change  due  to  the  proliferation  and  action  of  the  sporulated 
bacteria,  which  have  not  been  destroyed  by  sterilization  under  ordi- 
nary atmospheric  pressure.  This  consists  in  a  splitting  up  of  the 
casein  and  a  so-called  peptonization  of  the  milk.  This  change  begins 
after  a  few  days,  and  when  complete  renders  the  milk  alkaline  in 
reaction  and  sweetish  in  taste.  Milk,  unless  it  has  been  sterilized 
under  two  atmospheres  of  pressure  and  at  a  temperature  above  that 
obtainable  in  the  household  sterilizer,  is  never  completely  sterile. 
Milk  which  has  undergone  the  above  peptonization  is  unfit  for 
infant-feeding. 

Disadvantages    of    Sterilization    as    Compared   with    Pasteurization. — 
In  describing  sterilization  and  Pasteurization  of  milk,  it  has  been 


108  NUTBITION  AND  INFANT  FEEDING. 

intimated  that  sterilization  has  its  disadvantages,  and  these  are,  in 
short,  that  the  lactalbnniin  of  the  milk  is  coagulated  to  a  slight  degree ; 
the  casein  is  changed,  so  that  it  is  not  as  absorbable;  the  fats  are 
liquefied,  so  that  in  sterilized  mixtures  they  may  be  seen  on  the  sur- 
face in  the  form  of  an  oily  layer ;  and  the  lime  salts  are  converted  into 
unabsorbable  com^Dounds,  so  that  infants  taking  sterilized  milk  lose 
these  salts  for  the  economy.  They  do  not  get  the  necessary  bone 
pabulum.  This  would  account  in  part,  if  true,  for  the  prevalence  of 
scurvy  in  infants  who  take  sterilized  milk  as  an  exclusive  food  for 
too  long  a  period  of  time  (Cronheim  and  Miiller). 

Though  sterilization  was  at  first  a  great  step  in  advance,  in- 
asmuch as  the  process  presented  to  the  nursing  infant  the  possi- 
bility of  obtaining  its  food  in  a  wholesome  condition  hours  after  its 
preparation,  even  in  the  hottest  weather,  there  developed  certain 
disadvantages  in  connection  with  its  prolonged  use.  It  has  been 
noted,  partly  owing  to  the  increased  use  of  sterilized  milk  and  partly 
to  the  fact  that  bottle-feeding  has  become  much  more  general  to-day 
than  formerly,  that  infants  who  take  sterilized  milk  to  a  certain 
extent  do  not  thrive  as  well  as  infants  who  obtain  either  a  mixed 
diet  or  a  food  not  so  thoroughly  cooked.  The  result  has  been  a  de- 
cided increase  in  the  number  of  scurvy  cases,  undoubtedly  due  to  the 
changes  in  the  food.  Aside  from  the  danger  of  scurvy,  a  certain 
proportion  of  infants  who  do  not  develop  scurvy  and  who  are  fed 
exclusively  on  sterilized  milk  remain  stationary  in  weight,  although 
the  stools  of  such  infants  may  be  normal  in  appearance. 

Again,  infants  who  are  taking  sterilized  milk  develop  in  a  certain 
proportion  of  cases  inordinate  constipation,  and  this  in  itself  is  a 
very  troublesome  feature.  In  looking  for  another  method  of  preserv- 
ing the  infant  food,  at  least  here  in  America,  Pasteurization  was 
next  taken  up.  It  was  found,  however,  that  the  heating  of  the 
lactalbumin  even  to  a  temperature  of  70°  C.  had  its  disadvantages,  in 
that  a  certain  amount  of  lactalbumin  was  coagulated.  Still,  the  dis- 
advantages of  Pasteurization  are  less,  as  compared  to  those  of  sterili- 
zation, and  it  was  at  once  apparent  that  if  Pasteurization  could  be 
applied  as  a  method  of  preservation  of  infant  food,  it  would  be  a  step 
in  advance.  The  author  at  first  advocated  the  heating  of  milk  for 
infant-feeding  at  a  lower  temperature,  a  temperature  subsequently 
taken  up  by  Monti,  of  Vienna,  of  180°  F.  At  this  temperature  milk 
will  keep  twenty-four  hours  even  in  warm  weather,  with  ordinary 
care,  without  turning  sour.  Even  this  temperature  was  found  exces- 
sive, and  Freeman  advocated  a  still  lower  one  for  Pasteurization,  and 
devised  an  instrument  for  carrying  out  this  process,  which  to-day  is 
in  general  use. 

Coincident  with  the  agitation  against  sterilization,  and  even  Pas- 


TRE  FOOD  OF  TEE  INFANT.  109 

teurization  of  milk,  the  dairy  methods  have  been  so  improved  to-day 
that  the  time  of  Pasteurization  can  be  reduced,  and  in  midwinter,  in 
large  cities,  the  milk  can  be  obtained  in  such  purity  as  to  be  given  raw- 
to  the  infant.  The  whole  question,  therefore,  of  the  preservation  of 
milk  has  resolved  itself  into  obtaining  a  milk  as  free  from  impurities 
and  as  recently  from  the  dairy  as  possible.  Thus,  if  we  are  certain 
of  the  cleanliness  of  our  milk  and  the  care  with  which  it  is  handled. 
Pasteurization  can  be  followed  out  as  a  method  of  preservation  of 
the  infant's  food,  even  in  the  summer  time ;  but  such  Pasteurized 
milk,  no  matter  how  clean  the  original  milk  when  received  from  the 
dairy,  must  be  kept  carefully  on  ice  in  order  to  prevent  its  turning 
sour.  Among  the  poor  in  large  cities,  however.  Pasteurization  is  not 
safe  in  midsummer,  and  where  large  numbers  of  infants  are  fed  from 
laboratories  careful  sterilization  offers  the  best  safeguard  against  in- 
fantile summer  diarrhoea.  In  the  fall  and  winter.  Pasteurization,  in 
large  cities,  is  quite  sufficient  to  preserve  the  infant  food ;  and,  as  has 
been  stated,  in  winter  we  may  even,  if  we  are  sure  of  the  source  of 
our  milk  and  its  recency  from  the  dairy,  give  raw  milk  to  infants. 
Sterilization  and  Pasteurization,  therefore,  are  simply  methods  of 
preservation  of  infant  food,  and  have  nothing  intrinsic  in  themselves 
as  regards  the  problems  connected  with  infant-feeding. 

Experimental  Study   of  the  Assimilation  of  Sterilized,  Pasteurized 

and  Raw  Milk. 

Nitrogen  taken  Nitrogen  remaining 

in  milk.  in  feces. 

Grammes.  Per  cent. 
First  infant — 

Pasteurized  milk 10.9209  4.6 

Sterilized  milk 13.7449  4.9 

Raw  milk 5.3914  3.4 

Second  infant — 

Boiled  milk 32.643  4.5 

Sterilized  milk 30.969  4.3 

The  table  given  above  shows  the  comparative  digestibility  of  raw, 
Pasteurized,  and  sterilized  milk  (Koplik),  as  indicated  by  the  per- 
centage of  nitrogen  remaining  in  the  fseces  of  the  infant.  These 
experiments  were  performed  by  feeding  the  same  infant  with  raw 
and  heated  milk.  The  results  showed  that,  although  the  differences 
are  slight,  they  are  in  favor  of  milk  subjected  to  little  or  no  heat. 
Doane  and  Price  have  confirmed  these  results  by  experiments  on 
the  calf. 

What  Shall  the  Practitioner  do  in  Regard  to  Sterilization  and  Pasteuri- 
zation?— If  the  patient  has  access  to  a  milk  which  is  only  twelve 
hours  from  the  dairy  we  may  simply  Pasteurize  this  milk  both  sum- 
mer and  winter,  and  in  the  summer-time  it  should  be  carefully  kept 
on  ice.     During  the  winter  we  may  give  such  a  milk  raw  if  obtained 


110  NVTRiriON  AND  INFANT  FEEDING. 

from  a  mixed  herd  of  cattle.  Raw  milk  from  a  limited  herd  is  dan- 
gerous, inasmuch  as  the  dilution  is  not  great  enough  to  eliminate 
impurities  from  sick  cows,  should  there  be  such,  in  a  small  herd. 
The  practitioner  should  therefore  advocate  a  mixed  milk  from  a  large 
herd  as  the  best  safeguard  against  infection  of  the  infant.  The 
dairy  should  be  kept  scrupulously  clean,  as  should  also  the  animals, 
and  the  milk  kept  in  clean  utensils,  in  order  that  the  above  ideas  may 
prove  beneficial  to  infants.  If  the  infant's  milk  (modified)  is  to  be 
carried  any  distance  during  the  summer,  sterilization  is  a  safeguard 
for  a  short  period  of  time. 

Raw  Milk  in  Infant-Feeding.- — With  the  improved  methods  of 
dairy  hygiene  and  care  exercised  in  most  cities  in  the  collection  of 
milk  intended  for  infant-feeding,  the  milk  contains  less  bacteria  and 
reaches  the  infant  much  earlier  to-day  than  formerly.  The  result 
of  this,  at  least  in  IS^ew  York,  where  it  is  possible  to  obtain  milk 
within  twelve  to  twenty-four  hours  of  the  milking-time,  has  been  that 
the  milk  is  of  a  very  low  acidity  and  bacterial  content.  The  ques- 
tion arises  whether  we  may  not  give  such  milk,  modified  properly, 
in  a  raw  state  to  the  infant.  For  even  Pasteurization,  it  must  be 
admitted,  tends  to  change  the  ingredients  of  the  milk  to  such  an 
extent  as  to  compromise  their  nutritive  value. 

The  author  in  practice  Pasteurizes  the  infant's  milk  in  the  winter- 
time, and  in  many  cases  gives  the  milk  in  the  raw  state.  In  the 
summer,  however,  in  large  cities,  where  the  icing  of  milk  may  have 
been  imperfect,  it  is  safest  to  sterilize  the  milk  during  the  heated 
term.  This  is  only  for  a  period,  at  most,  of  three  months.  An 
infant  taking  sterilized  milk  under  proper  conditions  during  the 
heated  term  is  not  injured  by  such  a  food,  and  is  protected  from  an 
attack  of  gastro-enteritis,  for  it  is  not  possible,  even  though  great 
care  be  exercised,  to  prevent  an  occasional  bottle  of  milk  from  in- 
creasing in  acidity.  The  result  of  such  a  change  might  be  an-  attack 
of  diarrhoea  which  would  endanger  life.  In  the  fall,  wanter,  and 
early  spring  the  practitioner,  if  he  is  certain  the  milk  is  of  good 
quality  and  has  been  collected  in  a  careful  and  cleanly  manner,  need 
not  do  more  than  Pasteurize  the  milk.  If  he  is  absolutely  certain  of 
the  source  and  freshness  of  the  milk  he  may  even  give  it  raw.  There 
are  certain  infants  Avho  have  an  idiosyncrasy  against  the  taking  of 
raw  milk.  The  acidity  cannot  be  rectified  by  lime-water,  and  the 
result  is  that  such  infants  will  have  loose  movements  or  even  diar- 
rhtt'a.  These  cases  are  exceptional,  of  course,  but  they  must  be  borne 
in  mind.  In  exceptional  cases  the  author  has  seen  even  Pasteurized 
milk  disagree  in  the  same  manner  with  the  infant. 

Moreover,  we  know  now  that  the  administration  of  heated  milk, 
especially  sterilized  milk,  over  too  long  a  period  will  cause  bone  dis- 


TEE  FOOD  OF  THE  INFANT. 


Ill 


FiCx.  24. 


turbances,  and  it  is  certainly  unwise  to  give,  at  least  at  the  present 
day,  sterilized  milk  to  infants  in  the  cooler  seasons  of  the  year.  Even 
with  the  administration  of  Pasteurized  milk  for  any  length  of  time, 
it  is  well  at  about  the  fourth  to  the  sixth  month  of  infancy  to  give 
several  times  daily  a  small  quantity  of  diluted  orange-juice.  In  this 
way  the  ill  effects  of  heated  milk  are  counteracted,  and  the  infant  is 
supplied  with  those  salts  and  acids  which  are  lacking  in  the  Pasteur- 
ized and  sterilized  fluid. 

Frozen  Milk. — The  process  of  freezing  is  deleterious  to  cows^ 
milk,  inasmuch  as  it  breaks  up  the  original  fat-emulsion,  and  milk 
when  thawed  does  not  present  the  normal  appearance  under  the  micro- 
scope. The  individual  fat-globules  are  seen  to  be  angular,  and  in- 
stead of  presenting  a  spherical  refracting  body,  the  globule  presents 
concentric  rings,  showing  that  in  some  way  the  cold  has  acted  on  the 
fat.  Such  milk,  if  given  to  an  infant,  will  at  times  disagree  and 
cause  greenish  diarrha?al  movements,  sometimes  vomiting.  More- 
over, in  midwinter  it  is  very  common  for  children  who  have  pre- 
viously been  quite  regular  in  their  bowel  evacuations,  with  movements 
of  normal  consistence  and  appearance,  to  become  constipated  as  a 
result  of  the  ingestion  of  milk  which  has  been  frozen 
and  then  thawed.  It  seems  that  the  fat  of  the  milk 
undergoes  some  change  which  interferes  with  its 
hitherto  cathartic  action  on  the  bowels.  As  a  result, 
these  infants  will  have  hard,  constipated  movements ; 
or  the  movements  may  be  partly  constipated  or  partly 
of  normal  consistence.  In  such  cases  the  physician 
will  have  no  other  resource  but  to  advise  patience 
until  the  milk  can  be  delivered  in  an  unfrozen  condi- 
tion. 

Nursing  Bottle. — The  best  form  of  bottle  is  the 
so-called  Freeman  bottle  (Pig.  24),  which  has  very 
little  neck,  a  wide  mouth,  not  much  shoulder  to  the 
neck,  so  that  it  may  be  easily  cleansed.  For  newborn 
infants  there  is  now  constructed  a  very  small  bottle 
of  the  same  model  with  a  capacity  of  three  ounces, 
the  idea  being  that  when  milk  is  given  in  a  small 
bottle,  the  heat  is  retained  during  nursing  much  better  than  when  a 
small  quantity  of  milk  is  contained  in  a  large  bottle.  In  the  latter 
case  the  milk  is  chilled  before  the  termination  of  the  feeding.  When 
filled  the  bottles  are  corked  with  non-absorbent  cotton.  They  are 
corked  loosely,  so  that  the  steam  may  escape.  If  the  cotton  is  j  ammed 
tightly  into  the  bottle,  the  cork  will  blow  out  in  the  heating.  After 
nursing,  the  bottles  are  filled  with  a  solution  of  washing  soda  and 
allowed  to  stand  a  few  hours,  and  then  washed  externally  and  inter- 


Nursing  bottle 
of  the  Freeman 
model. 


112  NUTRITION  AND  INFANT  FEEDING. 

ually  aud  drained  dry.  Any  residue  of  milk  remaining  after  nursing 
should  not  be  utilized  for  another  nursing. 

The  cleansing  of  the  bottle  is  carried  out  with  a  so-called  bottle 
brush.  E'ipples  should  be  boiled  once  daily  for  ten  minutes,  and 
washed  with' hot  water  after  each  nursing.  It  is  well  to  have  several 
nipples  carefully  sterilized  in  the  early  morning  and  kept  in  a  clean 
jar,  rather  than  in  a  solution  of  boric  acid.  If  the  nipples  are  kept 
in  boric  acid  the  latter  is  apt  to  become  contaminated,  as  also  the 
nipples. 

Before  feeding,  the  bottle  of  milk  is  warmed  to  a  temperature  of 
about  100°  to  105°  F.  (40.5°  C),  so  that  the  milk  may  not  chill 
the  stomach  of  the  infant  and  thereby  suspend  the  digestive  process. 
Dr.  Sobel  has  constructed  a  bottle-warmer,  by  means  of  which  the 
milk  may  be  heated  to  exactly  the  same  temperature  at  every  nurs- 
ing.    This  is  sold  under  the  inventor's  name  in  the  shops. 

FOOD    PREPARATIONS. 

Peptonized  Milk. — With  the  perfection  of  our  methods  of  the 
modifications  of  cows'  milk,  either  in  the  laboratory  or  at  home,  the 
use  of  peptonizing  agents  as  an  aid  to  digestion  of  the  casein  of  the 
milk  has  become  more  and  more  limited.  On  the  other  hand,  it 
cannot  be  denied  that  the  addition  of  peptonizing  substances  in  safe 
quantities  to  the  milk  intended  for  the  infant  has  a  great  advantage 
in  certain  cases  of  difficult  casein  digestion.  As  a  rule,  the  infant 
will  not  take  kindly  to  completely  peptonized  milk.  It  has  a  bitter 
taste,  which  cannot  be  overcome  by  the  addition  of  sugar  or  any 
other  agent  to  the  milk.  We  are  thus  compelled,  at  least  in  the 
author's  experience,  to  introduce  the  peptonizing  agent  into  the  milk 
in  such  a  manner  as  not  to  change  the  taste  of  the  food.  The  best 
method,  therefore,  of  peptonizing  the  milk  for  infant-feeding  is  the 
so-called  cold  method.  This  is  done  as  follows:  The  milk  is  modi- 
fied, either  at  home  or  in  the  laboratory,  in  the  ordinary  way.  Just 
before  giving  to  the  infant,  if  the  amount  is  from  four  to  six  ounces 
at  each  feeding,  one-fifth  of  a  peptonizing  tube  is  added  to  the  mix- 
ture, which  is  then  well  shaken  and  placed  in  lukewarm  water  for 
two  and  a  half  minutes,  and  then  given  to  the  infant.  Such  a  milk 
will  not  have  a  perceptibly  bitter  taste. 

Another  method  of  peptonizing  milk  for  infant-feeding  is  to 
employ  the  so-called  peptogenic  milk  powder  for  this  purpose  sold 
in  the  shops.  A  bottle  of  modified  milk  containing  four  or  eight 
ounces  of  the  mixture  is  fortified  with  about  an  eighth  of  a  measure 
of  peptogenic  milk  powder  just  before  feeding,  heated  for  seven 
minutes  in  lukewarm  water,  and  then  given  to  the  infant.      Infants 


FOOD  PBEPABATIONS.  113 

may  be  kept  on  this  food  for  montlis,  and  then  when  the  digestion 
and  powers  of  assimilation  have  improved,  the  peptonization  may 
be  gradually  omitted.  The  author  has  seen  no  ill  effects  from  this 
method  of  giving  peptonized  foods.  He  feels,  however,  that  at  various 
intervals  during  the  feeding  of  such  infants,  attempts  should  be  made 
to  omit  the  peptonizing  ingredients  from  the  mixture,  in  order  to 
see  whether  the  infant  cannot  thrive  without  them. 

The  indications  for  the  use  of  peptonizing  infant  food  will  be 
given  under  the  heading  of  Difficult  Digestion. 

Condensed  Milk. — Condensed  milk  is  very  frequently  employed 
to  feed  infants  through  the  whole  of  the  nursing  period,  and  while 
it  cannot  be  denied  that  some  good  results  are  thus  obtained,  con- 
densed milk,  pure  and  simple,  for  the  majority  of  infants  is  not 
available.  Many  infants  will  cease  to  increase  in  weight  under  its 
continued  use;  others  will  develop  rachitis  and  scurvy. 

Condensed  milk  is  sold  in  the  shops  in  hermetically  sealed  cans, 
with  or  without  the  addition  of  sugar.  The  sugar  is  used  to  pre- 
serve the  milk,  and  is  generally  cane-sugar.  Condensed  milk  is  poor 
in  fats,  although  with  the  dilutions  customary  in  infant-feeding,  the 
proteids  are  not  only  low,  but  are  in  a  more  absorbable  state  than  in 
most  infant  foods.  Condensed  milk  also  contains  a  very  large  pro- 
portion of  sugar,  both  milk-  and  cane-sugar,  and  this,  as  has  been 
pointed  out  under  the  heading  of  ISTutrition,  is  one  of  the  most  easily 
absorbable  foods  for  the  infant. 

An  infant  successfully  fed  on  condensed  milk  will  show  a  large 
deposit  of  fat.  It  may  have  a  very  good  color,  but  a  critical  eye  will 
invariably  discover  evidences  of  faulty  metabolism,  such  as  rachitis. 
Condensed  milk  is  sometimes  of  great  value  in  cases  of  gastro- 
enteritis, in  which  the  digestion  of  ordinary  modifications  of  cows' 
milk  seem  to  be  unsuccessful.  It  should  only  be  used,  however,  in 
these  cases  to  tide  over  a  critical  period.  Condensed  milk  may  be 
used  fortified  with  cream,  and  under  such  conditions  the  cream  is 
well  assimilated.  In  traveling,  also,  if  good  milk  is  not  available, 
infants  who  have  been  fed  on  carefully  prepared  mixtures  may  tide 
over  a  period  of  a  few  days  on  dilutions  of  condensed  milk. 

The  following  composition  of  condensed  milk  is  given  by  Konig : 

Water.        Proteid.  Fat.  Sugar.         Ash. 

Condensed  milk  without   ^g^^g         ^^^^  ^^ ^^         j3  gg         j  99 

cane-sugar J 

With  the  addition  of  cane- 1  26.44         10.47  10.07         14.16        2.00 

sugar  38. 80  per  cent.  .    J 

In  order  to  prepare  condensed  milk  for  infant-feeding,  the  milk 
is  diluted  ten  to  twelve  times  for  infants  below  three  months  of  age, 


114  NUTBITION  AND  INFANT  FEEDING. 

and  five  to  six  times  for  older  infants.  In  the  cases  of  gastro-enteritic 
disturbance  above  mentioned,  when  the  assimilation  of  cows'  milk  is 
difiicult  in  the  period  following  subsidence  of  symptoms,  dilutions 
of  condensed  milk,  with  the  cautious  addition  of  raw  cream  or  top 
milk,  are  borne  better  than  modifications  of  cows'  milk.  This  method 
of  feeding  should  be  resorted  to  only  after  a  demonstration  of  the 
failure  of  milk  modifications,  and  should  only  be  preliminary  to 
feeding  with  fresh  cows'  milk. 

Barley-water. — Barley-water  is  one  of  the  most  useful  adjuvants 
either  to  modified  milk  mixtures  or  as  an  exclusive  food  for  a  short 
time  in  cases  of  gastro-enteritic  disturbances.  The  proper  preparation 
of  barley-water  has  been  the  subject  of  much  study.  The  simplest 
method  of  preparing  barley-water  is  that  which  utilizes  the  so-called 
Robinson's  Patent  Barley.  A  heaping  teaspoonful  of  Kobinson's 
Patent  Barley  is  suspended  in  a  pint  of  cold  water  until  the  lumps 
have  disappeared.  The  mixture  is  then  placed  in  a  small  saucepan 
over  a  gas-stove  fire,  and  stirred  constantly  for  fifteen  to  twenty  min- 
utes while  boiling.  The  more  the  barley-water  is  boiled,  the  more 
thoroughly  the  barley  is  dissolved  and  dextrinized.  After  boiling,  the 
loss  of  bulk  is  made  up  to  the  original  quantity  by  the  addition  of 
water.  The  use  of  the  so-called  dextrinized  barley  instead  cf  Robin- 
son's Patent  Barley  offers  in  certain  cases  advantages  to  which  refer- 
ence will  be  made  later  on.  Dextrinized  barley  is  sold  in  the  shops 
as  such.  It  is  made  up  of  barley-pearls  ground  and  heated  for  a  long 
period  of  time  according  to  the  formula  of  J.  Lewis  Smith.  The 
composition  of  Robinson's  Patent  Barley  is  given  by  Konig  as 
follows : 

Water 10.10 

Proteids 5.13 

Fats 0.97 

N.-free  extractives  (carbohydrates) 81.87 

Ash  1.93 

It  will  be  seen  by  a  study  of  its  composition  that  carbohydrates 
enter  into  it  very  largely.  Fats  and  proteids  are  present  in  very 
small  quantities.     It  is  therefore  unavailable  as  an  exclusive  food. 

Oatmeal  Gruel. — Oatmeal  is  utilized  in  the  same  manner  as  bar- 
ley to  dilute  milk.  It  is  made  up  in  the  form  of  a  gruel.  Two  or 
three  teaspoonfuls  of  oatmeal  are  boiled  in  a  pint  of  water  for  three 
hours  in  a  double  boiler  and  then  strained.  This  decoction,  made  up 
in  the  same  manner  as  the  barley,  is  utilized  to  dilute  milk  when 
barley  has  a  constipating  tendency. 

The  composition  of  oatmeal,  according  to  Munk,  is  as  follows : 


FOOD  PBEPABATIONS. 


115 


Water 10.1 

Proteids 14.7 

Fat      5.9 

Carbohydrates 64.7 

Eaw  fibre 2.4 

Ash 2.2 

Arrowroot  Gruel. — Arrowroot  gruel  has  been  used  from  time 
immemorial  to  dilute  milk,  especially  in  cases  of  summer  diarrhoea. 
Dr.  Merei  is  mentioned  hj  Routh  as  having  first  suggested  the  use  of 
this  cereal  for  diluting  milk.  A  teaspoonful  or  two  of  the  arrowroot 
is  added  to  a  pint  of  water  and  boiled  in  the  same  manner  as  starch 
and  oatmeal,  strained,  and  the  decoction  used  as  a  diluent  with  milk. 

The  composition  of  arrowroot,  according  to  Konig,  is  as  follows : 

Water 16.50 

Proteids 0.88 

Fat 0.10 

Carbohydrates 81.16 

Eaw  fibre 0.05 

Ash 0.19 

Beef -juice. — The  principal  beef-juices  are  Valentine's,  the  prep- 
aration called  Puro,  Bovinine,  Brand's,  Wyeth's,  Armour's,  and  Bur- 
goyne's  preparations  of  beef-juices.  Beef-juices  contain  little  protein 
and  much  extractive  matter,  so  that  the  nutritive  value  is  very  low. 
There  are  some  of  these  beef -juices,  such  as  Bovinine,  which  are 
manufactured  from  blood  rather  than  beef-fibre.     In  such  a  case  the 


Composition  of  Beef-juices. 

Valen- 
tine's.i 

Puro.2 

Bovin- 
ine.s 

Brand.* 

Wyeth.s 

Armour.e   ^  Bur-, 

W^ater 

Proteids 

Extractives  .... 
Mineral  matter   .    . 

Per  cent. 

51.21 

9.65 

11.16 

10.84 

Per  cent. 

36.60 

30.33 

19.16 

9.79 

Per  cent. 

81.09 

13.98 

3.40 

1.02 

Per  cent. 
59.15 
15.45 
16.55 

8.85 

Per  cent. 

44.87 

1  38.01 
17.12 

Per  cent. 

74.10 

r    8.30 

t    9.54 

7.51 

Per  cent. 

49.51 

13.00 

8.10 

14.20 

extractives  are  few  and  the  proteids  low;  they  are  more  in  use  than 
the  other  preparations.  In  order  to  take  enough  of  these  beef -juices 
to  equal  a  teaspoonful  of  scraped  meat  in  nutritive  value,  more  must 
be  taken  than  could  be  borne  by  the  average  stomach  in  illness 
(Hutchison).  They  are  not,  therefore,  available  as  exclusive  articles 
of  diet  for  any  length  of  time,  and  young  children  especialJy,  whose 

^  Analysis  by  Dr.  Candy. 

^  Fresenius  (Leyden's  Handbuch  der  Ernahrungstherapie). 

*Food  and  Sanitation,  Dec.  23,  1893  (Analysis  by  Chittenden). 

*  Analysis  by  Dr.  Candy  (unpublished). 

^  The  Lancet  Analysis  (quoted  by  the  makers). 

^Analysis  by  Dr.  Attfield  (supplied  by  the  makers). 

^  Analysis  by  Dr.  Candy. 


116 


NUTBITION  AND  INFANT  FEEDING. 


palates  are  capricious,  will  rebel  against  most  of  these  preparations, 
though  they  mav  prefer  those  which  contain  less  salt  than  others. 
They  are  useful,  therefore,  only  as  articles  of  diet  twice  or  three  times 
in  the  twenty-four  hours,  and  furnish  ingTcdients  in  the  shape  of 
water  and  salts  and  very  little  protein  to  the  body. 

Peptone  Preparations. — By  peptone  preparations  are  meant  such 
preparations  as  Somatose,  Carnrick's  Peptonoids,  Fairchild's  Pano- 
peptone,  and  others.  By  referring  to  the  table  the  reader  will  see 
that  there  are  quite  a  number  of  preparations  on  the  market.     Of 


Showing  the  Composition  of  Peptone  Preparations. 


Preparation. 

Water. 

Soluble  pro- 
teids  (chiefly 
albumoses). 

Extractives 
and  other  non- 

proteid  or- 
ganic matter. 

Mineral 

matter. 

Per  cent. 

Per  cent. 

Per  cent. 

Per  cent. 

Somatose 

9.20 

80.00 

6.70 

Carnrick's  peptonoids    .    . 

5.40 

24.00 

65.40 
(mainly  sugar) 

5.20 

Koch's  peptone 

40.16 

34.78 

15.93 

6.89 

Liebig's  peptone^   .... 

31.90 

33.40 

24.60 

9.90 

Brand's  beef-peptone      .    . 

84.60 

7.00 

L40 

Denaever's  peptone    .    .    . 

78.4.5 

12.15 

4.32 

2.54 

Darbv's  fluid  meat  ^    .    .    . 

25.71 

30.60 

30.18 

13.50 

Armoui-'s  wine  of  peptone^" 

83.00 

3.00 

12.90 

1.10 

Fairchild's  panopeptone" 

81.00 

6.00 

13.00 

(largely  sugar) 

1.00 

Peptonized  milk  ^^  .... 

87.50 

1.76 

10.04 

(=  sugar,  fat, 

and  unaltered 

proteid) 

0.70 

Liquid  peptonoids  ^^ 

(Arlington  Co.)  .... 

5.25 

12.63 

0.95 

the  peptonized  foods  in  a  ready  form,  the  most  concentrated  by  far 
is  Somatose,  which  contains  80  per  cent,  of  albumoses;  whereas 
other  preparations  contain,  as  will  be  seen  by  reference  to  the  table, 
very  little  proteid  matter,  and  are,  therefore,  of  very  slight  nutritive 
value.  Somatose,  however,  though  containing  as  it  does  the  greatest 
amount  of  proteid  matter,  cannot  be  taken  in  large  quantities  for  any 
length  of  time  without  causing  diarrhoea,  and  in  this  respect  it  is 
imavailable  as  an  exclusive  form  of  food.  In  feeding  infants  and 
children  I  find  it  is  of  the  greatest  value  in  those  cases  in  which  it  is 
necessary  to  give  the  stomach  absolute  rest  and  to  feed  per  rectum. 
For  such  cases  the  Somatose  is  prepared  as  follows:  A  teaspoonful 

*  Leyden  's  Handbuch  der  Ernabrungstherapie. 

'Ibid.     See  also  von  Noorden,  Therapeutische  Monatshefte,  June,  1892. 
"  Horton  Smith's  Journal  of  Physiology,  vol.  xii.,  p.  42,  1891,  and  Leyden 's 
Handbuch. 

"  Maker 's  analysis. 

'*Horton  Smith  (loc.  eit.). 

"  Maker 's  analj'sis  also  contains  14.94  per  cent,  of  alcohol  by  weight. 


FOOD  PBEPABATIONS.  117 

of  Somatose  is  dissolved  in  eight  ounces  of  cold  water.  Two  ounces 
of  this  solution  is  given  carefully  per  rectum,  care  being  observed 
to  pass  the  catheter  above  the  second  sphincter,  in  order  that  the  food 
may  not  be  rejected.  This  may  be  repeated  every  few  hours.  Thus 
given,  a  rectal  enema  is  absorbed  for  the  most  part,  and  in  some  cases 
it  may  be  mingled  with  milk  part  for  part,  the  nutritive  properties 
being  thus  increased. 

Butter  Milk. — Butter  milk  was  first  proposed  as  an  infant  food 
by  Ballot  in  1865  and  recently  revived  and  perfected  as  a  substitute 
for  the  breast  milk  by  Teixeira  de  Mattos.  According  to  the  latter 
it  is  prepared  as  follows:  A  litre  of  butter  milk  (commercial)  is 
mixed  with  a  level  tablespoonful  of  rice,  wheat  or  any  cereal  flour 
and  stirred  constantly  over  a  low  flame  for  25  minutes.  During  this 
time  it  is  brought  to  a  boil  three  times  after  having  added  two  to 
three  tablespoonfuls  of  cane  or  beet  sugar.  The  advantages  of  such 
a  mixture  for  sick  infants  is  that  it  has  a  very  low  fat  and  a  very 
high  proteid  content.  Inasmuch  as  the  mixture  has  been  boiled  and 
some  advise  that  bicarbonate  of  soda  be  added  to  a  point  of  alkalinity, 
the  acidity  of  the  butter  milk  and  its  supposed  bacterial  nature  have 
nothing  to  do  with  its  favorable  effects.  It  is  an  uncertain  food  to 
use,  as  some  butter  milks  are  distinctly  dangerous  and  their  prepa- 
ration has  not  yet  been  so  perfected  that  we  can  avoid  this  danger. 

Kumyss. — Kumyss  has  the  following  composition  (Konig)  : 

Water 90.44 

Alcohol 1.91 

Lactic  acid 0.91 

Milk  sugar 1.77 

Proteid 2.44 

Fat 1.46 

Ash 0.42 

Originally  kumyss  was  made  from  mares'  or  camels'  milk  by  the 
addition  of  a  ferment  indigenous  to  Tartary,  called  kefir.  To-day 
kumyss  is  manufactured  from  cows'  milk  by  the  addition  of  ordinary 
yeast-fungus,  and  contains,  as  will  be  seen  by  reference  to  the  table, 
a  certain  amount  of  alcohol  and  lactic  acid.  I  have  never  succeeded, 
even  for  a  short  period  of  time,  in  feeding  infants  on  kumyss  with 
any  amount  of  satisfaction.  It  is  only  available  in  illness  of  older 
children  with  capricious  palates.  Its  use,  therefore,  is  exceedingly 
limited.     The  same  may  be  said  of  Matzoon. 

Beef -extracts. — Beef -extracts  are  open  to  the  same  objections  as 
beef-juices,  in  that  they  contain  for  the  most  part  extractives  and 
are  not  intended  for  prolonged  periods  of  use.  There  are  prepara- 
tions, such  as  Bovril's,  which  contain  meat-fibre,  but  which  must  be 
given  in  such  concentrated  form  to  obtain  the  necessary  nutriment 


118 


NUTRITION  AND  INFANT  FEEDING. 


as  to  cause  diarrhoea.  Beef-extracts,  on  account  of  the  warmth  and 
contained  salts,  are  supposed,  when  administered,  to  stimulate  the 
appetite.  A  teaspoonful  of  Bovril's  is  equal  to  8  grammes  of  lean 
meat,  and  therefore  must  be  given  in  very  large  quantities,  as  stated 
above,  in  order  to  obtain  any  amount  of  nutrition. 

Beef-broth. — Beef-broth  has  a  composition  of  proteids  0.4,  fat 
0.6,  salts  1.2,  and  extractives  1.2.  With  the  extractives  beef-broth 
contains  creatin,  xanthin,  and  hypoxanthin. 

One  pound  of  meat  is  cut  up,  placed  in  one  pint  of  water,  and 
allowed  to  stand  for  four  or  five  hours.  It  is  then  cooked  over  a  slow 
fire  for  one  hour.  After  cooling,  the  fat  is  skimmed  off.  This  makes 
a  very  agreeable  beef -broth. 


Table 

Showing 

the   Composition 

of  Beef-extracts} 

Liebig's 
extract.2 

Bovril.3 

Bovril  for 
invalids.* 

Armour's 
extract.5 

Brand's 
essence. 6 

Vejos.f 

Water 

Proteids     .... 
Gelatin 

Extractives    .    .    . 
Mineral  matter     . 
Ether  extract,  etc 

Per  cent. 
18.3 

}"{ 

30.0 
23.6 
18.6 

Per  cent. 
44.40 
16.94 

20.32 
18.32 

Per  cent. 
21.82 
21.42 

39.60 
17.16 

Per  cent. 

15.55 

8.73 

2.16 

43.23 

25.91 

4.12 

Per  cent. 
87.17 
5.40 
5.03 
1.01 
1.39 

Per  cent. 
25.02 
19.35 

21.02 
14.07 
17.09 

(Carbo- 
hydrate). 

In  addition  to  the  above,  beef-broth  contains  phosphate  of  cal- 
cium, earthy  phosphates,  sodium  chloride,  oxide  of  iron ;  the  nutrition 
obtained  from  it  depends  mostly  on  the  salts,  especially  of  calcium 
combined  with  those  of  the  phosphorus. 

Acorn  Cocoa. — Acorn  cocoa  is  a  preparation  made  in  Germany, 
and  may  be  obtained  on  sale  in  the  shops.  The  author  has  found 
it  of  especial  use  in  cases  of  diarrhoea  and  intestinal  disease  in  which 
it  is  advisable  to  suspend  the  use  of  milk.  It  may  be  given  for  some 
days.  Children,  however,  object  to  its  taste,  and  for  this  reason  it 
is  not  applicable  in  every  case.  It  contains  fat,  nitrogenous  matter, 
and  tannic  acid.  A  teaspoonful  of  the  cocoa  is  dissolved  in  eight 
ounces  of  water,  and  the  preparation  is  given  warm  in  much  the  same 
manner  as  milk. 

^  Hutchison,  The  Lancet,  1902. 

^  Analysis  by  Tankard. 

^Analysis  by  Stiitzer  (quoted  by  Voit,  Miinchener  medicinische  Woehenschrift, 
No.  9,  1897). 

*  Analysis  supplied  by  the  company. 

"Food  and  Sanitation,  Dee.  16,  1893. 

'Analysis  by  Dr.  Candy   (unpublished). 

'  The  Lancet,  April  16,  1898,  p.  1060. 

N.  B. — "  Vejos  "  is  a  purely  vegetable  product,  but  is  included  in  this  table 
for  convenience. 


ARTIFICIAL  INFANT  FOODS.  119 

Stohlwerck's  acorn  cocoa  has  tlie  following  composition : 

Water  (Fresenius,  Konig) 5.28 

Proteids 14.06 

Fat 14.42 

Sugar 25.15 

Tannates 1.96 

Extractives 23.39 

ARTIFICIAL   INFANT    FOODS. 

Infant  foods  have  been  the  subject  of  much  investigation  on  the 
part  of  the  profession.  Scientifically  the  physician  is  correct  when 
he  maintains  that  children  cannot  be  brought  up,  as  a  rule,  on  the 
exclusive  use  of  any  infant  food. 

The  infant  foods  present  to  the  practitioner  either  dried  milk,  a 
cereal  in  combination  with  it  or  alone,  with  or  without  the  addition 
of  a  malt  preparation  of  some  kind.  It  is  quite  evident,  therefore, 
that  there  are  several  serious  objections  to  them  as  exclusive  articles 
of  diet  for  a  great  length  of  time.  The  principal  objection  is  that 
they  are  dried  or  heated  food  substances.  In  a  majority  of  cases 
this  is  a  dangerous  article  to  use  for  a  prolonged  period  in  infancy 
and  childhood  without  combining  it  with  some  fresh  article  of  diet, 
such  as  cows'  milk. 

Again,  many  of  the  infant  foods  contain  nothing  but  a  dry,  care- 
fully prepared  cereal.  ,  It  is  evident  that  this  alone  cannot  be  given 
as  an  exclusive  article  of  diet  to  an  infant.  It  may  be  administered 
for  a  short  time,  as  will  be  pointed  out  in  the  article  on  Infant- 
feeding;  but  it  cannot  be  given  for  any  prolonged  period  without 
giving  rise  to  those  very  symptoms  which  we  all  fear  referable  to  the 
bones  and  the  circulatory  system;  evidence  of  disturbed  nutrition, 
such  as  rachitis  and  scurvy. 

We  may  divide  infant  foods  roughly  into  three  groups :  The 
first  group,  such  as  AUenbury's,  Horlick's,  Carnrick's,  and  ISTestle's 
Food,  contain  cows'  milk  desiccated,  combined  with  some  cereal  and 
sugar.  These  foods  are  intended  as  an  exclusive  diet  for  infants, 
and  against  these  the  scientist  objects  principally.  They  are  foods 
which  cannot  be  applied  as  an  exclusive  food,  and  which  if  given  over 
a  prolonged  period  are  open  to  the  objections  stated  above. 

The  second  group  of  infant  foods  are  possibly  the  most  useful, 
and  are  those  which  contain  some  form  of  malted  carbohydrate.  The 
carbohydrates  are  in  soluble  form  and  the  food  may  be  regarded  as 
a  desiccated  malt  extract.  Some  of  these  preparations  also  contain 
diastase,  and  by  combining  the  food  with  cows'  milk  or  by  the  addi- 
tion of  some  carbohydrate  to  the  milk  we  can  obtain  a  combination 
which  is  not  only  digestible  for  the  infant,  but  may  be  of  great 


120 


NUTRITION  AND  INFANT  FEEDING. 


nutritive  value  for  a  short  period  of  time.  In  this  group  belong 
Melliu's  Food,  Loeflund's  Malt  Soup,  the  latter  being  nothing  more 
nor  less  than  the  Liebig  Malt  Extract  combined  with  potassium 
carbonate. 

The  third  group  of  infant  foods  are  those  vrhich  are  constructed 
of  a  pure  cereal,  and  in  this  group  are  Eidge's  Food,  Imperial 
Granum,  Eobinson's  Patent  Barley,  and  others.  This  last  group 
may  simply  be  considered  as  very  carefully  prepared  cereals.  They 
apply  in  those  cases  of  intestinal  disorder  in  which  it  is  desirable  for 
a  short  period  of  time  to  exclude  milk  completely. 

These  foods,   including   condensed   milk   previously   mentioned, 

Composition  of  Infant  Foods} 


Food. 


o      1      ^ 


General  description  and  remarks. 


^     S 


Dried  human  m.ilk  . 


Per  Per  Per  Per 
cent.  cent.  cent.  cent. 
12.20    26.40    52.40 


Geocp  I. 

Allenbury  No.  1    .   .   .      5.70 
(For  children  before 
the    age    of    three 
months.) 


Allenbury  No.  2    .   .  .      3.90 
(For  children  from 
the  age  of  three  to 
six  months.) 

Horlick's  malted  milk     3.70 


Camrick'B  soluble  food    5.50 


Nestl^'s  milk  food 


Manhu  infant  food  , 


5.50 


8.86 


GEorp  II.— Oasj  A 
Mellin's  food 6.30 


OoM  B. 
Savory  &  Moore's  food 


4.50 


9.70 

14.00 

9.20 

12.30 

13.80 

3.00 

13.60 

2.50 

ILOO 

4.80 

8.70 

5.60 

7.90 

trace 

10.30 

1.40 

1  10.20      1.20 

9.20 

1.00 

66.85 

72.10 
76.80 

76.20 

77.40 

75.90 

82.00 

83.20 
79.50 
82.80 


Per  I 
cent. 

2.10    The  standard  of  composition  to  which 
I     artificial   substances   should   con- 
form. 

3.75  Desiccated  cows"  milk  from  which 
the  excess  of  casein  has  been  re- 
moved, and  a  certain  proportion  of 
soluble  vegetable  albumin,  milk, 
sugar  and  cream  added.  No  starch 
present. 

3^  Resembles  the  above,  but  contains 
some  malted  flour  in  addition.  No 
starch  present. 

2.70  A  mixture  of  desiccated  milk  (hO  per 
cent.',  wheat  flour  (26i.i  per  cent.), 
barley  malt  (2Z  per  cent.),  and  bi- 
carbonate of  soda  1%  per  cent.i. 
Contains  no  unaltered  starch  when 
mixed. 

2.20  A  mixture  of  desiccated  milk  (STVi 
per  cent.  I,  malted  wheat  flour  (37i^ 
per  cent.  1,  and  milk-sugar  (25  per 
cent.  I.  When  prepared  accordinn 
to  directions  the  casein  is  partially 
digested,  but  a  considerable  amount 
of  unchanged  starch  is  left. 

1.30  A  mixture  of  desiccated  Swiss  milk, 
baked  wheat  flour,  and  cane-sugar 
(30  per  cent).  More  than  a  third 
of  the  total  amount  of  carbohy- 
drate is  in  the  form  of  starch. 

1.00  A  mixture  of  desiccated  milk  and 
malted  cereals.  When  prepared 
according  to  directions  contain.'^  a 
good  deal  of  unaltered  starch. 

3.80  A  completely  malted  food.  All  the 
carbohydrates  in  a  soluble  form. 
May  be  regarded  as  a  desiccated 
malt  extract. 

0.60    Composed  of  wheat  flour  with  the 

I     addition  of  malt. 
0.80    A  mixture  of  wheat  flour  and  pan- 

I      creatic  extract. 
0.50  I  A  mixture  of  wheat  flour  and  malt. 
When  prepared  according  to  direc- 
tions it  still  contains  some  unal- 
'     tered  starch. 


^Bobert  Hutchinson,  Lancet,  1902.     (Abbreviated  by  the  author). 


ABTIFICIAL  INFANT  FOODS. 


121 


Composition  of  Infant 

Foods  [Continued). 

Food. 

■6 

?2 

General  description  and  remarks. 

1 

2 

ss 

i^ 

Group  11.— Class  B 

Per 

Per 

Per 

Per 

Per 

(Continued). 

cent. 

cent, 

cent. 

cent. 

cent. 

Diastased  farina  .  .  . 

8.30 

7.60 

1.30 

81.70 

1.10 

A  malted  farinaceous  food.  When 
prepared  according  to  the  direc- 
tions, practically  all  the  starch  is 

converted  into  soluble  forms. 

Coomb's  malted  food 

7.90 

12.10 

2.80 

76.80 

0.40 

A  malted  farinaceous  food. 

Nutroa  food 

6.80 

15.90 

10.30 

66.00 

1.00 

A  mixture  of  cereals  with  the  addi- 
tion of  a  certain  proportion  of  pea- 
nut flour,  from  which  the  some- 
what bitter  taste  of  the  food  and  its 

Group  III. 

high  proportion  of  fat  are  derived. 

Ridge's  food 

7.90 

9.20 

1.00 

81.20 

0.70 

A  baked  flour,  containing  only  3  per 
cent,  of  soluble  carbohydrates,  the 
remainder  being  starch. 

Neave's  food 

6.50 

10.50 

1.00 

80.40 

1.60 

Resembles  the  above. 

Frame  food  diet   .  .   . 

5.00 

13.40 

1.20 

79.40 

1.00 

A  thoroughly  baked  flour  to  which 
have  been  added  cane-sugar  and 
some  extract  of  bran. 

Opmus  food 

10.90 

9.10 

1.00 

78.60 

0.40 

A  granulated  wheat  food. 

"Falona" 

7.00 

8.40 

8.50 

79.90 

1.20 

A  mixture  of  cereals  (oats,  barley, 
and  wheat),  with  a  ground  fat- 
containing  bean. 

Robinson's  groats    .   . 

10.40 

11.30 

1.60 

75.00 

1.70 

Ground  oats  from  which  the  husk 
has  been  removed. 

Robinson's  pat.  barley 

10.10 

5.10 

0.90 

82.00 

1.90 

Ground  pearl  barley,  poor  in  every 
element  except  starch  and  mineral 
matter. 

Chapman's  whole  flour 

8.40 

9.40 

2.00 

79.30 

0.90 

A  finely  ground  whole-wheat  flour. 

Scott's  oat  flour    .   .   . 

5.80 

9.77 

5.00 

78.20 

1.30 

A  fine  oat  flour. 

Addenda. 

Imperial  granum    .   . 

9.23 

14.00 

1.04 

75.34 

0.39 

(Classified  under  Group  III.) 

Eskay's  food 

8.58 

5.82 

1.16 

89.02 

1.30 

(Classified  under  Group  I.) 

show  a  deficiency  of  fat  and  an  excess  of  carbohydrates.  On  this 
ground  alone  their  prolonged  nse  is  objectionable.  The  proteids 
present  are  either  in  the  form  of  dried,  heated  proteids  of  cows'  milk, 
one  of  the  most  indigestible  forms  of  proteid  substances  that  can  be 
given  to  the  infant,  or  in  the  nature  of  vegetable  substances  which 
are  foreign  to  the  infant  dietary.  Condensed  milk  also  contains  such 
an  excess  of  sugar  as  to  cause  acid  dyspepsia ;  although  preparations  of 
condensed  milk  are  made  up,  as  has  been  stated,  without  sugar.  In 
the  treatment  of  enteritis,  both  of  the  acute  and  subacute  type,  it  is 
essential  in  very  young  infants  to  give  temporarily  some  form  of 
food  which  does  not  contain  milk  in  any  form.  Although  an  ordi- 
nary cereal  may  be  used  in  these  cases,  a  more  agreeable  form  is  one 
of  the  infant  foods,  and  especially  Imperial  Granum,  This,  made 
up  to  the  consistence  of  ordinary  barley-water,  may  be  administered 
in  cases  of  ileocolitis  for  quite  a  length  of  time,  and  will  not  be 
rejected  by  the  infant  or  young  child. 

At  the  period  of  weaning — the  ninth  month — cereals  may  be 
added  to  the  milk,  in  the  form  of  an  infant  food,  such  as  Ridge's 
Food,  Imperial  Granum,  or  barley.     In  such  cases  the  barley  or 


122  NUTRITION  AND  INFANT  FEEDING. 

infant  food  is  well  borne.  It  must  not  be  forgotten  also  that  in  the 
malted  foods,  wben  added  to  the  milk,  we  are  giving  a  form  of  sugar, 
malt-sugar,  one  of  the  most  digestible  carbohydrates. 

The  objection  raised  to  the  combination  of  malted  foods,  starchy 
cereals,  and  milk,  that  the  infant  is  not  capable  of  digesting  starch, 
does  not  obtain  fully  in  practice.  We  find,  as  will  be  shown  in  case 
of  the  dextrinized  gruels,  that  large  quantities  of  carbohydrate  and 
flour  may  be  given  to  infants,  and  their  digestion  will  not  only  be 
normal,  but  they  will  thrive  and  increase  in  weight  very  rapidly; 
whereas,  under  an  ordinary  milk  diet  they  have  remained  atrophic. 

MATERNAL   NURSING. 

The  ideal  food  for  the  infant  is  the  milk  of  the  mother  s  breast. 
Under  our  social  conditions,  the  mother  who  can  nurse  her  child 
from  birth  to  the  period  of  weaning  is  an  exception  to  the  rule,  not 
because  most  mothers  do  not  wish  to  nurse  their  infants.  On  the 
contrary,  the  author  has  found  them  very  anxious  to  perform  this 
function,  but  the  average  mother  to-day  has  not  the  physical  develop- 
ment that  fits  her  to  nurse  the  child.  The  result  is  that  she  cannot 
furnish  sufiicient  milk,  or  that  the  milk  is  not  of  the  quality  requisite 
for  successful  nursing.  Some  mothers  will  have  a  sufficiency  of 
so-called  milk.  The  infants,  however,  do  not  gain  in  weight,  are 
puny,  have  attacks  of  colic,  and  the  symptoms  indicate  that  the  food 
is  at  fault.  Examination  shows  that  in  such  women  true  milk  secre- 
tion is  rarely  established;  the  milk  remains  in  the  colostrum  stage. 

Some  physicians  think  that  if  the  infant  cannot  have  the  benefit 
of  the  maternal  breast  a  wet-nurse  is  the  alternative.  If  with  the 
wet-nurse  we  had  simply  to  consider  the  fitness  of  the  food,  this  would 
be  true.  If  the  maternal  breast  is  not  at  our  disposal,  the  next  best 
and  the  safest  thing  for  the  race  is  a  substitute  for  the  breast,  for 
many  reasons,  some  of  which  we  will  try  briefly  to  indicate. 

In  the  first  place,  it  is  not  moral  nor  conducive  to  the  future 
good  of  the  race  to  ask  a  mother  (the  wet-nurse)  to  put  aside  her 
own  child  and  to  deprive  it  of  the  breast  for  the  sake  of  a  strange 
child. 

Second.  ISFo  matter  how  healthy  a  wet-nurse  may  be  at  the  time 
of  examination,  we  have  no  assurance  that  such  a  wet-nurse  will 
remain  healthy,  or  that  some  diathesis  not  apparent  at  the  time  of 
examination  may  not  be  transmitted  to  the  infant  (Czerny).  We 
thus  take  a  healthy  infant,  place  it  at  a  breast,  and  feed  it  with  milk 
concerning  the  ultimate  influence  of  which  we  are  utterly  in  the  dark. 
The  author  is  inclined  to  believe  that  so  far  as  human  milk  is  con- 
cerned, certain  tendencies  may  be  conveyed  from  the  nurse  to  the 


MATEBNAL  NUBSING.  123 

infant  which  will  crop  out  later  in  life.  Bj  this  he  refers  rather  to 
scrofulous  tendencies,  lymphatic  tendencies,  tendencies  connected 
with  diseases  of  the  blood-forming  organs. 

Third.  The  introduction  of  a  stranger  into  the  household  is  a 
cause  of  great  disturbance  to  that  household,  and  also  one  of  concern 
to  the  physician.  The  idea  that  a  child  brought  up  at  the  breast  is 
better  fitted  for  the  struggle  for  existence  may  be  true ;  on  the  other 
hand,  the  difficulties,  at  least  in  this  country,  of  obtaining,  fit  wet- 
nurses  for  children  are  so  great  that  it  would  be  well,  if  the  mother 
cannot  nurse  the  infant,  to  place  it  on  a  substitute  in  the  form  of 
bottle-feeding,  unless  this  is  not  feasible. 

Of  course,  in  all  this  we  do  not  include  those  exceptional  infants 
which  cannot  be  fed  artificially.  Such  cases  occur,  and  must  be 
placed  upon  the  breast. 

Finally,  if  the  mother  can  furnish  two  or  three  nursings  daily,  it 
is  well  not  to  take  the  child  off  the  breast  entirely,  but  to  institute 
what  is  known  as  mixed  feeding.  In  some  cases  this  is  a  very  satis- 
factory method  of  feeding  the  infant. 

Contraindications  to  Maternal  Nursing. — A  mother  may  suffer 
from  syphilis  or  skin  eruptions  or  may  have  a  deficiency  of  milk  and 
under  certain  conditions  may  still  be  allowed  to  nurse  her  infant.  A 
ivet-nurse  should  be  free  from  all  constitutional  and  psychical  taint 
to  nurse  an  infant. 

Syphilis  can  be  communicated  to  the  wet-nurse  by  the  infant,  or 
to  the  infant  by  the  wet-nurse  through  luetic  lesions  of  the  nipple. 
A  syphilitic  infant,  therefore,  must  not  be  allowed  to  nurse  the  breast 
of  a  woman  who  is  free  from  syphilis ;  and  we  should  be  very  careful 
not  to  place  a  child  free  from  syphilis  on  the  breast  of  a  wet-nurse 
without  previous  careful  examination  as  to  the  presence  of  syphilis 
in  the  nurse.  A  mother,  on  the  other  hand,  who  has  syphilis  can 
nurse  her  infant  without  danger  of  communicating  syphilis  to  the 
infant  if  the  mother  has  been  exposed  to  and  contracted  the  disease 
up  to  a  period  of  two  months  before  the  delivery  of  the  child.  An 
infant  congenitally  syphilitic  may  nurse  its  mother  without  commu- 
nicating the  disease  to  the  mother.  These  facts  have  been  well  estab- 
lished, and  have  been  commented  on  in  the  chapter  on  Syphilis. 
Should  the  mother  have  contracted  syphilis  subsequent  to  the  birth 
of  her  infant,  and  should  she  have  been  nursing  the  infant,  it  would 
be  wise  to  take  the  infant  away  from  the  breast,  for  such  a  mother 
may  communicate  the  syphilis  to  the  infant  in  the  same  manner  as  a 
syphilitic  wet-nurse. 

Tuberculosis  in  the  mother,  even  in  its  milder  manifestations,  is 
a  contraindication  to  her  nursing  her  infant.  Though  the  manner 
in  which  the  toxins  of  the  tubercle  bacillus  or  the  bacillus  itself  pass 


124  NUTBITIOX  AND  INFANT  FEEDING. 

into  the  breast  milk,  if  sucli  be  the  case  at  all,  is  still  a  matter  of 
study,  sve  can  well  understand  ho"«'  the  mother,  weakened  by  the 
inroads  of  such  a  disease  as  tuberculosis,  would  be  further  seriously 
injured  and  weakened  by  nursing  her  child.  The  close  contact  of 
mother  and  nursling,  furthermore,  might  favor  the  infection  of  the 
infant  in  other  ways  than  by  the  milk  alone.  On  the  other  hand,  an 
old  focus  of  tuberculosis,  such  as  a  healed  pleurisy  or  coxitis  long 
healed,  in  a  vigorous  mother  would  not  contraindicate  nursing  should 
the  secretion  of  milk  be  abundant  and  should  the  function  not  make 
inroads  upon  her  health. 

Active  symptoms  of  Bright's  disease,  such  as  general  anasarca 
and  other  signs  of  serious  involvement  of  the  kidney,  would  preclude 
a  mother's  nursing  her  infant,  not  only  because  such  a  function  would 
weaken  her,  but  because,  metabolism  being  profoundly  disturbed,  the 
breast  milk  would  be  unfit  for  the  maintenance  of  the  nutrition  of 
the  infant. 

Advanced  disease  of  the  heart  would  also  unfit  a  woman  for 
nursing  her  infant.  On  the  other  hand,  a  slight  albuminuria  not 
giving  any  objective  or  subjective  symptoms  should  not  interfere 
with  the  desire  of  the  mother  to  nurse  her  offspring.  Advanced 
and  active  disease  of  the  liver  would  in  the  same  manner  as  the  above 
diseases  contraindicate  nursing. 

Organic  nervous  disease  with  paralysis,  severe  neuroses,  insanity, 
hysteria,  epilepsy,  neurasthenia  of  a  marked  type,  when  present  in 
the  mother,  contraindicate  the  nursing  of  the  infant.  Aside  from 
the  disturbances  said  to  be  caused  in  the  infant  nursing  the  breast  of 
a  person  the  subject  of  hysterical  or  epileptic  attacks,  we  would 
scarcely  care  to  trust  such  a  sufferer  with  the  care  of  an  infant.  On 
the  other  hand,  slight  nervous  tendencies  in  the  mother  should  not 
contraindicate  the  nursing  of  the  infant,  for  in  such  a  case  we  would 
open  the  way  for  the  deprivation  of  the  breast  to  a  large  number  of 
infants,  and  give  an  easy  avenue  of  escape  to  some  from  the  responsi- 
bilities of  maternity.  The  severe  forms  of  anaemia,  leukaemia,  ma- 
lignant disease,  such  as  carcinoma  and  sarcoma,  the  presence  of  a 
very  miarked  goitre  vrith  active  symptoms,  may  be  mentioned  as  con- 
traindications to  the  nursing  of  an  infant. 

The  acute  contagious  diseases,  the  exanthemata,  erysipelas,  pneu- 
monia, bronchopneumonia,  pleurisy,  acute  rheumatism,  typhus  and 
typhoid  fever,  diphtheria,  are  all  contraindications  to  nursing  the 
infant.  I  have  seen  mothers  suffering  from  erysipelas  nurse  their 
infants  without  infecting  them.  This  should  not  be  the  rule,  how- 
ever. In  a  case  of  diphtheria  the  danger  to  the  infant  of  infection 
is  much  greater  than  would  be  counterbalanced  by  the  benefits  to  be 
attained  from  continuance  at  the  breast.     The  milk  of  a  woman  suf- 


PLATE  VI 


FIG.   1 


Form  of  the  Breasts  of  a  Wet-nurse  >A^ith  Abundant 

Milk  of  Good   Quality.      (After  Sehliehter  ) 


FIG.  2 


Form    of  the    Breasts    of  a    ^A/■et-nurse    whose    Milk    is 
Deficient  in  Quantity  and  Quality.    (After  sehiichter.) 


MATEBNAL  NUBSING.  125 

fering  from  a  severe  pneumonia  with  a  high  febrile  curve  cannot  be 
all  that  is  desired  for  the  infant,  and  the  process  of  nursing  with  the 
accompanying  physical  and  mental  disturbance  might  react  against 
the  mother. 

Selection  of  a  Wet-nurse. — It  is  not  necessary  that  the  wet- 
nurse  should  have  been  recently  delivered.  A  newborn  baby  may  be 
given  the  breast  of  a  nurse  whose  baby  is  from  one  to  two  months  of 
age.  In  fact,  her  milk  is  preferable  to  that  of  a  nurse  who  has  just 
been  confined.  For,  apart  from  the  uncertainty  as  to  whether  the 
milk  will  agree  with  the  baby,  the  milk  after  a  few  weeks  attains  a 
uniform  composition,  and  is  more  likely  to  agree  with  the  baby  than 
milk  from  the  breast  of  a  woman  recently  confined.  I  prefer  to  place 
the  newborn  infant  on  a  breast  at  least  three  weeks  old. 

The  method  of  examining  a  wet-nurse  as  to  her  fitness  begins 
with  ascertaining  the  history  of  her  own  baby.  It  should  sleep  well 
in  the  intervals  of  nursing,  be  free  from  colic,  and  have  normal  move- 
ments. The  baby  should  be  completely  undressed  for  examination. 
It  should  be  at  least  tolerably  well  nourished.  There  should  be  no 
eruption  on  the  skin,  no  copper-colored  intertrigo,  no  snuffles,  no  pig- 
mented spots,  and  no  rhagades  around  the  mouth  or  anus.  The  skin 
of  the  palms  of  the  hands  or  the  soles  of  the  feet  should  not  be  fissured 
or  hard  or  present  suspicious  pigmentation.  The  head  should  not 
have  an  idiotic,  microcephalic  conformity.  The  wet-nurse  should  be 
below  the  age  of  thirty.  Old  multiparse  do  not,  as  a  rule,  furnish 
good  milk.  The  shape  of  the  breast  is  important.  The  pear-shaped, 
elongated,  hanging  breast  furnishes  more  milk  than  the  firm,  round 
breast  of  virgin  shape  (Plate  VI.).  The  nipple  should  be  about  one 
centimetre  long  and  three-fourths  of  a  centimetre  in  diameter.  The 
baby  can  easily  grasp  such  a  nipple  and  draw  it  into  the  mouth.  A 
flat  nipple,  or  a  nipple  with  fissures,  or  a  nipple  surrounded  by  eczema 
is  not  desirable  in  a  nurse,  and  may  even  be  dangerous  to  an  infant. 
The  nurse  is  next  directed  to  undress,  and  her  body  is  examined  for 
traces  of  any  eruption  which  may  be  specific.  Pigmented  macules 
should  arouse  suspicion,  as  also  enlarged  cervical  or  epitrochlear 
lymph-nodes.  The  lungs,  especially  the  apices,  are  examined  for 
bronchitis  or  tuberculosis.  The  nurse  is  rejected  if  there  be  the 
slightest  evidence  of  apical  involvement.  The  teeth  should  not  be 
carious  to  such  an  extent  as  to  preclude  the  possibility  of  their  being 
kept  clean.  The  presence  of  a  foetid  ozsena  is  highly  objectionable, 
apart  from  the  offensive  odor.  Such  cases  may  be  latently  tuber- 
culous. The  woman  should  be  mentally  sound.  The  wet-nurse  is 
then  examined  as  to  the  presence  of  venereal  disease  by  inspection 
of  the  introitus  vaginse  and  the  anus.  The  mucous  membrane  of 
the  mouth  should  be  examined  for  evidences  of  syphilis.     Search  is 


126  NUTRITION  AND  INFANT  FEEDING. 

made  for  mucous  patches  and  suspicious  cicatrices.  After  having 
examined  both  child  and  mother  in  the  manner  detailed,  we  are  in  a 
position  to  recommend  the  nurse  if  the  milk  is  satisfactory. 

The  physician  should  have  at  hand  in  his  office  means  by  which 
he  can  at  once  decide  upon  the  desirability  of  a  wet-nurse.  He  must 
not  at  the  beginning  be  driven  to  the  necessity  of  a  milk  analysis. 
He  decides  first  as  to  the  quantity  and  then  as  to  the  quality  of  the 
milk.  As  a  rule,  a  wet-nurse  comes  to  the  physician  insufficiently 
fed  and  in  a  frame  of  mind  far  from  tranquil.  If  despite  these  con- 
ditions the  milk  possess  the  qualities  desired,  he  may  at  once  venture 
to  place  the  baby  at  her  breast.  If  the  milk  does  not  agree  with  the 
baby  after  a  fair  trial,  future  conduct  will  be  guided  by  certain 
developments,  both  in  the  quantity  and  quality  of  the  milk  and  the 
condition  of  the  infant. 

Quantity  of  the  Milk. — The  physician  grasps  the  breast  in  the 
palm  of  his  right  hand  and  gently  but  firmly  attempts  to  express 
the  milk.  The  milk  should  with  gentle  pressure  flow  freely  from 
the  ducts.  A  drop  is  caught  on  the  nail  of  the  thumb.  This  time- 
honored  nail-test  is  not  to  be  despised.  A  drop  of  good  milk  will 
retain  its  bluish-white  tint.  This  test  will  bring  out  the  color  of 
the  milk,  whether  too  watery,  yellow,  or  white,  to  the  experienced 
eye.  The  nurse  is  then  directed  to  pump  by  gentle  pressure  a  quan- 
tity of  milk  into  a  long,  narrow  beaker  glass.  If  the  breast  has  not 
been  nursed  within  an  hour,  there  should  be  no  difficulty  in  obtaining 
at  least  an  ounce  of  milk  in  this  way.  With  this  quantity  we  can 
at  once  decide  on  the  efficiency  of  a  nurse.  The  milk  should  have  a 
bluish-white  tinge.  Any  trace  of  yellow  or  green  when  a  test-tube 
of  the  milk  is  held  in  the  light,  is  abnormal.  Milk  may  be  very 
abundant  but  of  a  dirty  white  tinge ;  some  specimens  separate  almost 
instantly  upon  withdrawal  into  a  yellowish  oily  layer  on  top  and  a 
serous  liquid  below.  Any  such  abnormalities  in  the  milk  should 
cause  the  rejection  of  an  applicant.  If  the  breasts,  history,  and 
physical  examination  are  satisfactory,  and  the  quantity  and  physical 
characteristics  of  a  nurse's  milk  are  good,  we  may  recommend  her 
without  making  a  chemical  examination  of  the  milk.  Such  an 
examination  is  impracticable  for  the  practitioner  with  the  means  at 
his  disposal.  Even  if  carried  out,  it  may  be  unfair  to  the  nurse. 
At  the  examining  visit  the  proportion  of  proteids  and  fats  may  be 
below  what  it  will  adjust  itself  to  in  a  day  or  two  when  the  wet-nurse 
is  rested  and  housed  in  her  new  home.  More  nutritious  diet  will 
greatly  change  the  composition  of  the  milk.  There  are,  however, 
conditions  which  may  require  an  examination  of  the  milk  at  a  sub- 
sequent period.  In  such  a  case  the  methods  detailed  elsewhere  may 
be  resorted  to. 


MATERNAL  NUESING.  127 

The  Beginning-  of  Nursing. — Once  having  determined  to  place 
the  infant  at  the  breast,  the  question  arises,  When  should  this  func- 
tion be  begun  ?  Immediately  after  birth  the  mother  is  tired  and  so 
is  the  infant.  They  have  both  gone  thought  a  critical  period.  It  is 
well  to  let  them  rest  for  some  hours.  If  the  infant  sleeps,  and 
awakens  only  to  be  changed  as  to  its  diaper,  we  should  not  hasten 
to  feed  it.  The  author  follows  the  rule  that  the  infant  be  given  a 
little  water  at  intervals  from  the  first  six  hours  until  the  beginning 
of  the  next  day  after  birth,  and  then  the  mother,  having  been  thor- 
oughly rested,  the  child  is  put  at  the  breast,  even  though  there  are 
but  a  few  drops  of  colostrum  in  the  breast. 

The  first  day  after  birth  the  infant  should  be  fed  at  intervals 
of  three  hours.  At  this  time  there  will  be  very  little  in  the  breast, 
but  the  stimulation  of  the  breast  by  nursing  will  cause  an  increased 
secretion  of  milk,  so  that  by  the  second  day  nursing  may  be  inaugu- 
rated at  regular  intervals  of  two  hours.  After  this  the  intervals  of 
nursing  are  so  apportioned  that  the  newborn  infant  during  the  first 
week  will  obtain  the  breast  from  nine  to  ten  times  in  the  twenty-four 
hours ;  the  second  week,  eight  or  nine  times  in  the  twenty-four  hours ; 
and  in  the  fourth  week,  eight  times  in  the  twenty-four  hours.  After 
this  the  intervals  of  nursing  will  be  much  the  same  as  they  are  in 
artificial  feeding.  We  give  the  breast  at  intervals,  generally  of  two 
and  a  half  hours,  so  that  the  last  nursing  is  at  11  p.  m.  After  the 
first  month  the  infant  should  sleep  until  five  or  six  o'clock  in  the 
morning,  when  it  obtains  the  first  nursing.  Then  from  the  second 
to  the  sixth  month  seven  nursings  in  the  twenty-four  hours  are  suffi- 
cient. The  nursing  should  be  so  arranged  that  the  mother  and  child 
may  have  complete  rest  of  five  hours  between  12  p.  m.  and  5  a.  m. 

The  number  of  times  an  infant  should  nurse  at  the  breast  is  in 
the  large  majority  of  cases  a  matter  of  training  and  habit,  especially 
with  the  breast-fed  infant.  Czerny,  following,  Ahlf eld  advises  placing 
the  baby  at  the  breast  on  the  average  of  five  times  in  the  twenty-four 
hours.  With  care  and  patience  this  can  be  done.  The  practitioner, 
however,  will  meet  a  number  of  mothers  who  will  nurse  their  offspring 
more  frequently,  and  the  above  gives  the  limit  of  such  nursings.  In 
frequent  nursing  the  infant  receives  less  at  each  feeding  than  in  the 
nursings  at  longer  intervals. 

Care  of  the  Breast. — The  care  of  the  breast  really  begins  before 
the  birth  of  the  infant.  About  the  seventh  month  of  pregnancy  colos- 
trum appears  in  the  breast.  At  this  time  it  can  be  seen  in  some  cases 
to  exude  from  the  nipple.  Unless  care  is  taken  at  this  time  we  will 
have  a  fissuration  of  the  breast  nipple,  due  to  the  action  on  the  epi- 
thelium of  the  skin  of  the  drops  of  colostrum  which  are  allowed  to 
collect  and  decompose  on  the  nipple.     The  result  is  that  at  birth 


128         •  NUTBITION  AND  INFANT  FEEDING. 

the  mother  may  have  sufficient  milk  in  the  breast,  but  be  unable 
to  nurse  the  child  on  account  of  the  presence  of  these  fissures,  I 
advise,  therefore,  that  at  this  time  of  pregnancy  the  nipples  be  kept 
scrupulously  clean  and  washed  twice  a  day  with  a  dilute  solution  of 
alum  water  or  some  antiseptic  wash.  In  this  way  the  decomposition 
of  colostrum  on  the  nipple  is  avoided,  and  the  nipple  is  strengthened 
by  the  slight  massage  of  washing.  If  the  nipple  is  not  well  devel- 
oped, this  is  the  time  also  to  attempt  its  development.  This  is  done 
by  drawing  out  the  nipple  twice  a  day,  either  with  the  clean  fingers 
or  by  means  of  suction.  A  small  clay  pipe  may  be  used  for  this  pur- 
pose, and  the  future  mother  may  draw  out  the  nipple  by  means  of 
suction  with  this  simple  instrument.  I  am  certain  if  this  hygiene  of 
the  nipple  is  pursued  that  fissures  of  the  nipple  will  be  less  frequent. 

Fissured  Nipples.- — Ordinarily,  if  the  nipple  of  the  breast  is  kept 
dry  and  clean,  it  will  not  fissure  and  eczema  will  not  occur.  Fissures, 
however,  sometimes  occur  even  when  great  care  has  been  taken  to 
prevent  them.  Fissures  or  rhagades  appear  in  about  one-half  of  the 
nursing  women.  They  are  present  either  on  the  summit  of  the 
nipple  or  at  its  base.  In  the  latter  situation  they  are  in  the  form  of 
linear  or  circular  ulcers.  If  fissures  of  the  nipple  are  painful,  the 
infant  should  not  nurse  the  breast  directly,  but  through  a  shield 
which  protects  the  nipple,  the  best  form  being  the  Davidson  shield. 
The  fissure  is  painted  once  daily  with  a  10  per  cent,  solution  of 
nitrate  of  silver.  If  there  is  a  discharge  of  visible  pus  from  the 
fissure,  or  if  the  breast  nipple  has  a  point  of  suppuration  ever  so 
small,  the  breast  should  not  be  nursed,  for  by  so  doing  the  mother 
may  develop  abscess  of  the  breast  or  the  infant  may  contract  an 
infectious  diarrhoea. 

Physicians  insist  on  placing  infants  at  the  breast  immediately 
after  delivery,  for  two  reasons:  first,  because  it  is  said  that  suction 
at  the  breast  favors  contraction  of  the  uterus.  Whether  with  this 
function  there  is  contraction  of  the  uterus  has  not  been  proved. 
Again,  it  is  said  that  at  this  time  suction  will  favor  the  flow  of  milk. 
Milk  with  colostrum  does  not  appear  to  an  appreciable  amount  in 
the  breast,  if  not  previously  present,  before  twenty-four  to  seventy- 
two  hours  or  even  eight  days  after  delivery.  If,  as  has  been  pointed 
out,  the  breast  is  nursed  too  frequently,  the  traumatism  caused  by  a 
vigorous  infant  will  give  rise  to  erosions  of  the  nipple,  and  thus 
fissures.  An  excellent  nursing  breast  may  be  ruined  by  over-zealous 
efforts  on  the  part  of  the  physician.  Fissures  once  present,  if 
unyielding  to  the  methods  detailed  above,  must  be  allowed  to  heal  by 
giving  the  breast  perfect  rest.  Some  women  will  nurse  an  infant  at 
the  breast,  the  nipples  of  which  are  the  seat  of  fissuration,  without 
pain,  caking,  or  inconvenience.     In  other  women  caking  will  take 


MATERNAL  NURSING.  -  129 

place,  with  intense  pain  on  nursing,  and  lymphangitis  and  abscess 
result.  In  all  such  cases  of  pain,  lymphangitis,  and  caking  nursing 
is  best  suspended,  the  infant  being  placed  temporarily  on  the  bottle. 
The  breasts  are  supported,  the  fissures  painted  daily  with  silver,  and 
if  caking  is  present  the  breasts  are  emptied  carefully  with  the  pump 
and  massage  of  the  breasts  performed.  If  after  the  breasts  become 
soft  and  the  fissures  are  entirely  healed  there  is  still  a  little  milk  in 
the  breast,  the  infant  may  be  put  again  at  such  a  breast,  and  if  the 
organ  is  in  a  normal  state  the  stimulation  of  suction  will  start  a 
proper  milk  secretion.  I  have  done  this  in  a  case  in  which  the 
breasts  had  been  at  rest  for  three  weeks  after  delivery,  with  excellent 
results.  The  milk  returned  in  abundance,  without  unnecessary  trau- 
matism to  the  breast,  the  infant  nursing  only  three  times  daily  at 
first.  We  should  never  expose  a  mother  to  the  danger  of  abscess  of 
the  breast  by  persistent  attempts  at  nursing  fissured  nipples. 

Caking  of  the  Breast.- — After  the  birth  of  the  infant,  the  breast 
should  be  closely  watched  to  prevent  the  so-called  caking  of  the  milk. 
If  the  infant  is  not  strong  and  does  not  nurse  well,  there  will  be  a 
residual  amount  of  milk  in  the  breast.  After  nursing,  this  milk 
should  be  pumped  off  with  a.  breast-pump.  The  most  satisfactory 
breast-pump  is  one  with  a  glass  bell  and  a  rubber  bulb.  Pumping 
the  breast  at  first,  when  the  milk  is  forming,  will  prevent  caking  and 
rapidly  regulate  the  secretion  to  the  normal  amount.  On  the  other 
hand,  if  a  fissure  of  the  nipple  is  present,  caking  is  more  apt  to 
occur,  on  account  of  the  pain  attendant  on  emptying  the  breast,  either 
by  nursing  or  by  means  of  the  breast-pump.  We  should  be  exceed- 
ingly cautious  in  these  cases  to  examine  the  breast  repeatedly  in  order 
that  areas  of  caking  may  not  escape  us. 

If  caking  occurs,  the  breast  should  be  rubbed  or  massage  per- 
formed three  times  daily.  The  hands  of  the  nurse  are  carefully 
washed  and  anointed  with  some  sterilized  oil.  The  breast  is  grasped 
in  the  palms  of  both  hands,  one  above  and  the  other  beneath.  The 
breast  is  then  gently  subjected  to  firm  pressure  with  a  vermicular 
motion.    This  massage  is  kept  up  for  five  or  ten  minutes. 

Nursing  the  Infant. — The  infant  should  nurse  about  twenty 
minutes  and  then  fall  asleep  at  the  breast.  The  nipple  is  washed 
with  a  solution  of  boric  acid  before  and  after  each  nursing,  and  is 
covered  in  the  intervals  of  nursing  with  a  small  piece  of  absorbent 
gauze  folded  several  times.  In  this  way  the  nipple  does  not  come 
in  contact  with  the  clothing,  and  any  exuding  milk  is  caught  on  the 
gauze,  which  is  replaced  by  a  clean  piece  whenever  necessary.  The 
infant  while  nursing  should  lie  in  the  arms  of  the  mother  or  the 
nurse.  The  nurse  grasps  her  breast  just  behind  the  base  of  the 
nipple  with  the  index  and  ring  fingers;  the  thumb  should  be  used 

9 


130  NUTBITION  AND  INFANT  FEEDING. 

to  exert  pressure  on  the  breast  and  thus  regulate  the  flow  of  milk. 
In  this  way  the  infant  is  prevented  from  drawing  the  nipple  too  far 
into  the  mouth.  The  habit  of  moistening  the  breast  with  saliva  or 
a  few  drops  of  milk  is  reprehensible.  The  infant's  mouth  will  fur- 
nish all  the  moisture  needed. 

Signs  of  Efficient  Breast-feeding.— An  infant  nursed  at  the 
breast  is  thriving  if  it  has  a  good  color,  if  its  weight  increases  in 
regular  ratio,  if  it  sleeps  between  the  nursings,  and  the  stools  are 
normal  in  color.  It  may  be  said  in  this  place  that,  as  to  the  stools, 
they  will  vary  even  in  the  most  thriving  infant,  both  in  color  and 
consistence,  from  time  to  time.  An  infant  who  is  otherwise  in  good 
health  and  is  not  suffering  from  any  disturbance  of  the  gut  will  have 
from  time  to  time  slightly  fluid,  yellow  movements ;  at  other  times 
the  movements  may  contain  a  few  whitish  curds ;  and  at  other  periods, 
even  the  most  thriving  breast-fed  infants  may  show  in  the  stools 
greenish  discolored  particles.  If  the  infant  shows  no  other  signs  of 
disturbance  and  is  in  good  spirits,  these  changes  in  the  color  and 
consistence  of  the  movements  should  not  give  us  concern ;  they  are 
dependent  on  the  varying  composition  of  the  breast-milk.  If  the 
milk  contains  on  certain  days  more  fat  than  usual,  the  movements 
may  be  softer  and  more  frequent  than  customary.  If  the  proteids 
are  increased  in  quantity  they  may  even  show  a  greenish  tinge. 
These  conditions,  however,  must  be  infrequent  and  should  not  carry 
with  them  disturbances,  such  as  colic,  restlessness,  or  stationary 
weight. 

I  have  seen  infants  who  were  thriving,  in  that  they  had  a  very 
good  color  and  their  weight  increased,  but  they  suffered  from  inordi- 
nate colic,  and  examination  of  the  breast  milk  showed,  even  at  the 
second  month  of  infancy,  quite  a  number  of  colostrum  corpuscles. 
After  certain  hygienic  hints  were  carried  out  by  the  mother,  these 
colostrum  corpuscles  disappeared  from  the  milk,  the  colic  abated, 
and  the  infant  returned  to  a  normal  condition.  Disturbances,  there- 
fore, of  the  gut  are  not  always  an  indication  for  the  cessation  of 
maternal  breast-nursing. 

Signs  of  IneflBcient  Breast-feeding. — An  infant  is  not  thriving 
on  the  breast  milk  if  its  weight  remains  stationary  for  any  length 
of  time.  For  this  reason  infants  should  be  weighed  once  a  week  at 
first,  and  after  the  second  month  at  least  twice  a  month.  At  the 
first  indication  of  stationary  weight  an  infant  should  be  weighed 
every  three  days,  in  order  to  see  whether  there  is  any  increase  under 
new  conditions.  If  the  weight  continues  stationary  the  milk  should 
be  examined.  It  may  be  deficient  in  quantity  to  such  an  extent  as 
to  no  longer  satisfy  the  child.  In  that  case  the  infant  will  be  ob- 
served to  nurse  the  breast  for  a  long  time,  or  it  may  nurse  the  breast 


MATERNAL  NURSING.  131 

a  short  time  and  then  relinquish  the  nipple  and  cry ;  or  it  may  cry 
in  the  intervals  of  nursing.  All  these  are  signs  of  inefficient  feed- 
ing. In  such  cases  the  breast  should  be  examined  just  before  a 
regular  nursing,  in  order  to  estimate  the  quantity  of  milk  in  the 
breast.  The  infant  should  be  weighed,  then  given  the  breast,  and 
weighed  after  nursing  is  completed.  The  breast  is  also  examined 
after  nursing.  In  this  systematic  way  we  can  estimate  the  amount 
of  milk  taken  by  the  infant  at  that  particular  nursing. 

The  movements  of  infants  fed  on  an  inefficient  breast  as  to  the 
quantity  of  milk  are  dry,  constipated,  and  small.  The  author  has 
seen  the  character  of  the  stools  improve  upon  increasing  the  quantity 
of  food,  either  from  the  breast  or  by  supplementing  the  breast  with 
the  bottle.  In  some  cases  the  infant  cries  and  has  colic,  the  move- 
ments are  passed  with  much  flatus,  and  are  uneven  in  consistence, 
lumpy  here  and  there,  with  green  discoloration.  In  such  a  case  the 
quantity  of  the  milk  may  be  sufficient,  but  its  quality  is  not  up  to 
the  requisite  standard.  The  nurse's  milk  should  be  examined  not 
only  chemically,  but  microscopically.  A  single  chemical  examina- 
tion of  the  milk,  as  has  been  stated,  gives  no  definite  information. 
The  milk,  therefore,  of  the  morning  and  evening  nursings  should  be 
examined. 

It  may  again  be  emphasized  that  colic  alone  or  combined  with 
slight  variations  in  color  and  consistence  of  the  infant's  stools  is  not 
a  justification  for  the  suspension  of  nursing.  An  infant  may  gain  in 
weight,  have  good  color,  and  still  have  inordinate  colic.  With 
patience  and  hygienic  exercise  on  the  part  of  the  nurse  colicky 
attacks  will  ultimately  grow  less  frequent,  and  many  infants  who 
suffered  colic  at  first  will,  as  the  second  month  approaches,  cease 
to  have  colic  as  soon  as  the  milk  has  definitely  assumed  a  uniformly 
normal  composition.  Infants  who  thus  have  suffered  colic  at  the 
second  or  third  month  after  birth  will  cease  to  be  inconvenienced 
and  will  thrive  from  this  time  forward. 

If  an  infant  at  the  breast  fails  to  increase  in  weight,  and  at  the 
same  time  suffers  from  inordinate  colic,  has  green,  curdy  movements 
or  a  slight  tendency  to  diarrhoea,  it  becomes  a  very  important  ques- 
tion as  to  whether  it  is  not  better  to  take  such  a  child  from  the 
breast  entirely,  and  to  place  it  either  on  another  breast  or  a  substi- 
tute for  the  breast.  An  examination  of  the  breast  milk  will  aid  us, 
as  has  been  intimated  elsewhere.  If  this  breast  milk  reveals  to  any 
marked  degree  elements  such  as  colostrum  corpuscles  and  fails  to 
show  the  characteristics  of  normal  breast  milk,  we  will  still  be  more 
anxious  to  take  such  an  infant  from  the  breast.  In  fact,  a  con- 
tinuation of  an  infant  at  such  a  breast  is  sometimes  not  devoid  of 
danger.     In  one  case  the  continued  attacks  of  colic,  accompanied  by 


132  NUTRITION  AND  INFANT  FEEDING. 

fLuid  movements,  with  green  curds  from  birtli,  resulted  ultimately  in 
an  attack  of  intussusception.  This  occurred  in  an  infant  five  months 
of  age.  After  the  operation  the  infant  was  placed  on  the  mother's 
breast  again,  and  had  a  return  of  the  former  symptoms — constant 
colic,  green  curdy  movements,  alternating  at  times  with  slight  diar- 
rhoea. It  was  taken  off  the  breast  immediately,  placed  on  an  artificial 
substitute,  and  throve. 

MIXED    FEEDING. 

Mixed  feeding  is  the  administration  of  the  breast,  supplemented 
by  the  bottle  containing  some  substitute  for  the  milk  lacking  in  the 
breast.  Infants  who  are  nursed  on  an  inefficient  breast  as  regards 
quantity  of  milk  should  be  carefully  weighed,  and  the  quantity  of 
milk  in  the  breast  estimated  for  the  twenty-four  hours.  This  may 
be  done  by  weighing  the  infant  before  and  after  each  nursing,  or 
can  be  roughly  estimated  by  simply  observing  the  amount  of  milk 
that  can  be  pumped  off  from  both  breasts  combined  two  hours  after 
•a  feeding.  Having  measured  the  milk,  we  can  estimate  within  cer- 
tain limits  the  amount  of  milk  which  such  a  breast  would  yield  in 
twenty-four  hours.  If  there  is  sufficient  milk  in  the  breast  for  even 
two  nursings,  the  mother  should  not  be  denied  the  pleasure  of  nursing 
her  infant.  We  should  not  hastily  reject  such  a  breast  as  worthless, 
for  two  feedings  of  breast  milk  will  be  a  great  aid  to  the  infant, 
both  in  the  development  of  bone  and  the  other  tissues  of  the  body. 
If  two  nursings  exist  in  the  breast,  we  would  give  the  bottle  six 
times  in  the  twenty-four  hours  to  an  infant  below  the  age  of  three 
months,  and  five  times  in  the  twenty-four  hours  to  an  older  infant. 

In  feeding  on  the  bottle  in  combination  with  the  breast,  we  should 
begin  as  we  do  in  the  newborn,  with  a  low  percentage  of  fats  and 
proteids.  Having  accustomed  the  infant  to  the  bottle,  we  should 
gradually  work  up  to  the  normal  percentage  of  fats  and  proteids,  as 
will  be  shown  in  the  chapter  on  the  Feeding  of  Infants.  The  details 
as  to  the  construction  of  the  food  are  the  same  as  those  followed  out 
with  the  infant  fed  upon  the  bottle  exclusively. 

Care  should  be  exercised  in  these  cases  to  avoid  overfeeding. 
Mothers  are  especially  prone  to  overfeed  infants,  having  an  idea  that 
a  fat  baby  is  a  healthy  one ;  but  if  it  is  explained  to  the  mother  that 
fat  does  not  mean  health,  overfeeding  may  be  avoided.  This  is 
especially  true  of  mixed  feeding;  such  infants  are  apt  to  be  overfed 
and  to  be  overweight,  for  the  mother  who  has  two  nursings  of  the 
breast  will  be  apt  to  consider  this  of  very  little  moment  and  attempt 
to  feed  on  the  bottle,  as  if  the  infant  had  nothing  from  the  breast  at 
its  disposal.  The  result  is  that  such  infants  frequently  suffer  from 
overflow  vomiting.     In  many  cases  this  overflow  vomiting  does  not 


ARTIFICIAL  FEEDING  OF  INFANTS.  133 

seem  to  disturb  the  infant  to  any  appreciable  degree.  It  should  be 
avoided,  however,  for  such  vomiting  may  at  any  time  become  a  matter 
of  serious  moment. 

ARTIFICIAL    FEEDING    OF    INFANTS. 

Artificial  feeding  of  infants  is  the  substitution  for  the  breast  milk 
of  some  one  of  the  foods  considered  in  the  previous  pages.  Although 
attempts  have  been  made  to  rear  infants  artificially  on  asses'  or  goats' 
milk,  the  experiment  has  failed,  and  cows'  milk  is  universally  utilized 
as  a  substitute  for  the  mother's  breast  in  artificial  infant-feeding. 

Before  cows'  milk  can  be  given  to  the  infant  as  a  food  it  must  be 
modified,  that  is,  the  fats,  proteids  and  sugar  must  be  rearranged 
and  diluted  into  an  easily  assimilable  mixture. 

There  are  two  methods  now  well  recognized  of  modifying  cows' 
milk  for  infant-feeding.  One  of  these  methods  is  the  so-called  labora- 
tory method  of  infant-feeding.  The  laboratory  method  or  Botch's 
method  of  infant-feeding  attempts  to  recombine  the  fat,  proteids,  and 
sugar  of  milk  not  only  in  proportions  which  conform  to  what  is  found 
in  human  milk,  but  to  attempt  to  find  out,  by  the  frequent  changing 
of  these  constituents,  what  is  best  adapted  to  each  infant.  Rotch 
and  his  school  contend  that  what  is  good  for  or  adapted  to  one  infant 
may  not  be  suitable  for  another.  In  his  own  words :  "  What  is  one 
infant's  food  may  be  another's  poison."  The  Eotch  method  of 
infant-feeding  has  now  had  a  very  extensive  and  thorough  trial.  Its 
successes  and  failures  will  be  considered  later  on.  The  difficult  cases 
of  infant-feeding  baffle  the  most  skilful  efforts  at  modifying  cows' 
milk.  It  is  fallacious  to  assume  that  the  proteids  and  fats  of  cows' 
milk  can  be  assimilated  without  change  in  the  economy. 

The  old  methods  of  infant-feeding  considered  simply  the  dilution 
of  the  whole  milk  two  or  three  times,  either  with  simple  water  or  with 
some  decoction  of  a  cereal,  either  barley  or  arrowroot.  In  the  first 
month  the  milk  was  diluted  one  in  three ;  in  the  second  month,  one  in 
two ;  in  the  third  month,  two  in  three,  etc.  These  simple  methods 
continued  in  use  until  Biedert,  in  Germany,  and  Meigs,  in  the  United 
States,  attempted  to  proportion  the  casein,  fat,  and  sugar  so  as  to 
make  the  mixture  approach  the  composition  of  human  milk.  Biedert 
called  his  food  a  cream  mixture.  It  was  made  in  the  same  general 
way  as  Meigs'  mixture.  There  was  a  low  percentage  of  proteids,  and 
a  fat  percentage  corresponding  to  what  is  found  in  human  milk.  The 
proteids  in  Meigs'  mixture  ranged  from  1.2  to  1.5  per  cent.  In 
Biedert's  mixture  the  proteids  existed  to  the  extent  of  1  per  cent.,  fat 
2  to  2.5  per  cent.,  sugar  4  per  cent.  Meigs'  mixture  contains  3.5  per 
cent,  of  fat  and  6  per  cent,  of  sugar. 


134 


NUTRITION  AND  INFANT  FEEDING. 


Biedert's  Mixture. — Biedert  took  50  ounces  of  milk,  or  1.5  litres, 
and  allowed  it  to  stand  one  hour.  The  cream  taken  off  the  top  of 
this  milk  contained  10  per  cent,  of  fat.  The  amount  of  cream  was 
8  ounces.  In  other  words,  the  top  8  ounces  off  50  ounces  of  milk 
was  a  10  per  cent,  top  cream.  It  will  be  seen  from  this  that  his  top 
milk  method  is  identical  with  that  now  in  vogue  in  this  country. 
With  this  he  constructed  the  following  formulae. 


Number  of 
mixture. 

Cream  (10 
per  cent.). 

Water. 

Milk-sugar. 

Milk. 

Casein. 

Fat. 

Sugar. 

Litre. 

Litre. 

Grammes. 

Litre. 

Per  cent. 

Per  cent. 

Per  cent. 

I. 

i 

1 

18 

(=  1.0 

2.5 

5.) 

II. 

i 

f 

18 

tV 

(=  1.4 

2.6 

5.) 

III. 

i 

3 

s 

18 

i 

.  (  =  1.5 

2.6 

5.) 

IV. 

i 

s 
s 

18 

i 

(=  1.8 

2.8 

5.) 

V. 

i 

3. 

18 

8 

(=  2.1 

2.3 

5.) 

VI. 

1 
4 

12 

1 
2 

(=  2.3 

2.4 

5.) 

If  we  compare  these  formulae  with  Meigs'  mixture,  we  find  that 
Meigs  contended  that  the  infant  needed  through  its  whole  nursing 
period  practically  one  formula. 

Meigs  therefore  had : 


1.  A  16-ounce  top  milk  [7  to  8  per  cent,  of  fat]. 

2.  A  solution  of  milk-sugar,  15  per  cent. 

3.  A  solution  of  lime-water. 


He  combined  them  as  follows : 

!3  ounces  of  top  milk. 
3  ounces  of  sugar  solution. 
2  ounces  of  lime-water. 

This,  according  to  our  present  methods,  would  give  approximately 
a  mixture  of  3  per  cent,  of  fat,  1.3  per  cent,  of  proteids,  6  per  cent, 
of  sugar,  which  is  also  what  Meigs  strove  for,  with  the  exception 
that  in  some  milks,  as  has  been  shown,  more  fat  would  be  obtained 
than  that  given  above,  which  is  calculated  from  an  average  milk. 
With  some  milks  Meigs  obtained  4.7  per  cent,  of  fat.  To  be  more 
concise,  Meigs  designed  the  above  method  to  obtain : 

Water 87.6^. 

Fat 4.7 

Casein 1.1  iMeigs'  artificial  food. 

Sugar 6.2 

Salts 0.2  J 

It  will  be  seen  from  the  standpoint  of  to-day  that  both  these  men 
were  pioneers  of  percentage  feeding.     It  may  be  mentioned  here  that 


ABTIFICIAL  FEEDING  OF  INFANTS.  135 

the  method  of  Escherich  is  based  on  an  attempt  to  calculate  with 
rough  dilutions  of  milk  the  amount  of  albumin  necessary  for  the 
daily  maintenance  of  nutrition.  So  far  as  the  author  knows,  the 
Escherich  method  is  little  in  vogue  in  America. 

The  other  two  methods  of  modifying  milk,  which  calculate  the 
gross  amount  of  calories  necessary  to  maintain  nutrition  for  infants, 
are  the  Huebner-Hoifman  and  the  Soxhlet  method.  They  have  en- 
deavored to  construct  a  chemical  mixture  with  the  aid  of  cows' 
milk  which  is  equal  to  the  raw  nutritive  calories  in  mother's  milk. 
In  both  these  methods  the  milk  is  diluted  with  an  equal  amount  of 
water.  Huebner-Hoifman  uses  as  a  diluent  a  6  per  cent,  solution  of 
milk  sugar  whereas  Soxhlet  uses  a  9  per  cent,  solution.  The  addition 
of  sugar  of  milk  is  intended  to  take  the  place  of  fats,  which  are  de- 
ficient in  these  mixtures.  Sugar  of  milk,  according  to  Soxhlet,  has 
a  caloric  value  equal  to  that  of  the  fat  deficit. 

If  it  is  desirable  to  feed  a  great  number  of  infants  in  a  public 
laboratory,  I  can  say  from  actual  experience  that  these  mixtures  are 
of  the  greatest  utility,  inasmuch  as  they  can  be  easily  prepared,  and 
certainly  the  greater  number  of  infants  thrive  on  them.  It  is  almost 
impossible  in  a  laboratory  intended  for  the  use  of  the  poor  of  a 
great  city  to  give  each  child  a  percentage  mixture.  In  other  words, 
the  feeding  en  masse  is  an  entirely  different  problem  from  the  feed- 
ing in  private  practice. 

Infants  from  the  first  to  the  third  month  do  not  thrive  as  well 
on  the  Huebner-Hoffman  and  Soxhlet  mixtures  as  they  do  on  modifi- 
cations obtainable  by  the  home  method,  which  will  be  described.  In 
other  words,  infants  below  the  third  month  get  in  these  mixtures  an 
excess  of  proteids  and  deficiency  of  fat.  The  Meigs'  mixture  is  more 
applicable  to  these  cases. 

The  Rotch  Method.- — The  method  of  Rotch  has  as  its  pivotal 
point  the  fact  that  all  infants  cannot  be  fed  on  the  same  mixture,  and, 
taking  the  composition  of  human  milk  as  a  working  basis,  each  infant 
should  be  considered  as  a  separate  problem  in  constructing  a  formula 
which  within  certain  limits  would  be  most  suitable  to  its  needs. 
Rotch  therefore  separates  the  milk  from  the  cream  by  means  of  a 
separator  or  by  gravity,  and  working  with  skimmed  milk  and  cream 
containing  16  or  20  per  cent,  of  fat  and  a  dilution  of  milk-sugar,  the 
constituents  of  the  milk  are  rearranged.  By  this  method  an  infant 
can  be  fed  on  a  mixture  of  1.5  per  cent,  of  proteids,  3  per  cent,  of  fat, 
and  6  per  cent,  of  sugar;  or  1.5  per  cent,  of  proteids,  2.5  per  cent, 
of  fat,  and  6  per  cent,  of  sugar,  or  any  percentage  of  proteids,  fat, 
and  sugar  that  we  may  desire  to  give.  Rotch  also  contends  that  an 
infant  which  may  not  thrive  on  1.2  per  cent,  of  proteids  might  do  so 
on  1.5  per  cent.     The  proportion  of  fat  may  be  reduced  or  increased 


136  NUTRITION  AND  INFANT  FEEDING. 

as  needed  in  the  individual  case.  In  other  words,  the  physician 
should  consider  his  percentage  formula  in  feeding  the  infant,  just  as 
he  prescribes  a  certain  strength  of  a  drug. 

To  obtain  these  percentages  a  laboratory  is  needed,  and  to-day 
laboratories  for  supplying  these  mixtures  to  be  used  in  the  percent- 
age feeding  of  infants  are  to  be  found  in  large  cities.  Though 
theoretically  this  method  of  reconstructing  the  milk  would  seem  on 
the  surface  to  be  the  most  rational,  it  has  certain  inherent  defects. 
These  defects  are  much  the  same  as  those  of  the  older  methods. 

1.  By  simply  rearranging  the  proteids,  fat,  and  sugars  we  do  not 
change  the  proportionate  relationship  which  the  casein  or  caseinogen 
bears  to  the  lactalbumin  and  other  proteids  of  the  milk,  and  we  do 
not  in  any  way  change  the  foreign  nature  of  these  to  the  human 
economy. 

2.  With  the  exception  of  a  few  limited  facts  and  formulae  we 
have  no  data  which,  with  our  present  knowledge,  will  enable  us  to 
know  in  every  case  when  to  increase  or  to  diminish  the  proteids  and 
also  the  fats. 

3.  The  process  of  separating  the  cream  from  the  milk  by  ma- 
chinery destroys  the  original  delicacy  of  the  fat-emulsion  in  the  milk. 
The  infant  does  not  assimilate  these  mixtures  in  every  case  as  well  as 
those  which  are  constructed  from  milk  which  has  not  been  manipu- 
lated to  the  extent  that  laboratory  milk  has. 

In  order  to  utilize  the  Rotch  method  by  means  of  the  laboratory, 
the  physician  has  simply  to  prescribe  the  percentages  that  he  re- 
quires on  a  slip  made  out  for  the  purpose  and  furnished  by  these 
laboratories.  It  is  needless  to  say  that  unless  a  physician  is  satis- 
fied to  follow  a  routine  common  to  all  his  cases,  instead  of  trying  to 
understand  the  needs  of  each  infant,  he  is  certain  to  meet  cases 
which  even  the  most  accurate  modifications  of  the  laboratory  will 
not  cause  to  thrive.  In  other  words,  the  laboratory  alone  will  not 
enable  the  physician  to  feed  infants  successfully.  To  do  this  he 
must  know  not  only  the  percentages  required  at  certain  ages  from 
constructed  formulae,  but  must  study  the  digestion  of  each  child,  its 
movements,  and  try  to  analyze  whether  certain  elements  of  the  milk 
such  as  the  fats  are  in  excess  or  in  diminished  quantity.  It  may  be 
said  that  in  practice  children  can  get  along  on  a  very  few  fixed 
formulse.  An  infant  which  will  not  thrive  on  these  formulae  within 
certain  limits  will  not  thrive  on  any  percentage  modification  of  cows' 
milk,  no  matter  how  we  may  rearrange  the  percentages  of  its  in- 
gredients. 

Principles  Underlying  the  Rotch  Method  of  Percentage  Feeding. — 
As  has  been  intimated,  we  must  distinguish  very  carefully  between 
infants  who  are  quite  normal  and  those  suffering  from  intestinal  dis- 


AETIFICIAL  FEEDING  OF  INFANTS.  137 

turbances  in  feeding  them  with  cows'   milk.     The  healthy  infant 
needs  but  very  few  changes  of  formulae  throughout  its  infant  life. 

The  first  fact  to  be  ascertained  is  whether  the  infant  is  capable 
of  digesting  cows'  milk  at  all.  If  such  is  the  case,  by  a  careful  be- 
ginning and  modification  of  milk  we  can  carry  the  infant  along  on 
very  few  formulae,  possibly  three  or  four,  through  its  period  of  infancy. 

Proteid. — The  total  amount  of  proteids  in  the  cows'-milk  mix- 
tures must  be  very  low  for  the  newborn  infant,  certainly  not  to 
exceed  1  per  cent,  during  the  first  week.  After  this  the  proteids  are 
increased  or  kept  at  this  point  until  the  third  month,  when  they 
are  increased  to  about  1.5  per  cent.,  and  we  may  increase  them  until 
the  ninth  month.  For  vigorous  infants  of  heavy  weight  we  may 
increase  the  proteids  at  the  sixth  month  to  2  per  cent. 

Fats.— The  fats  in  the  first  days  after  'birth  should  be  low — 
from  1.5  to  2  per  cent.  After  the  second  week  to  the  third  month 
we  may  give  from  2.5  to  3  or  3.5  per  cent,  of  fat;  rarely  more  than 
this.  The  reason  for  this  is  that  during  this  period  the  infant  will 
not  digest  more  fat.  Infants  who  are  getting  a  larger  amount  of  fat 
than  the  percentage  indicated  will,  as  the  nurse  puts  it,  frequently 
"  spit  up  "  curds  between  the  feedings.  All  the  movements  will  be 
frequent,  soft,  and  in  some  cases  even  of  an  oily  consistence  or  soapy 
in  look  and  constipated.  In  other  words,  infants  who  are  taking 
a  greater  proportion  of  fat  than  that  indicated  will  have  a  mild  fat- 
diarrhoea,  which  may  at  any  time  become  more  severe  and  give  rise  to 
considerable  concern.  From  the  third  month  to  the  termination  of 
infancy  the  fats  may  range  from  3  to  3.5  or  even  4  per  cent. ;  never 
more  than  this.  Infants  who  are  taking  high  percentage  fat  mixtures 
will  increase  in  weight,  up  to  a  certain  point  apparently  thriving, 
and  then  will  be  noted  to  become  pale,  with  constipated,  dry,  formed 
movements. 

Sugar. — In  modifying  milk  the  sugars  are  placed  in  the  mix- 
ture at  a  uniform  percentage  of  6  per  cent.  It  is  rare  for  us  to  be 
called  upon  to  alter  this  percentage  to  any  considerable  extent.  Too 
much  sugar  will  cause  in  some  cases  fermentation  in  the  gut,  result- 
ing in  the  production  of  gas.  The  children  may  thrive  for  a  time 
on  an  excess  of  sugar ;  but  in  all  these  cases,  sooner  or  later,  a  point 
is  reached  at  which  the  sugar  is  no  longer  tolerated  in  large  percent- 
ages. It  is  therefore  unwise  to  give  a  larger  percentage  of  sugar 
than  that  indicated. 

Salts. — The  salts  of  the  cows'  milk  are  scarcely  considered  in 
modifications.  We  know  very  little  to-day  about  the  fate  of  the 
salts  in  the  cows'  milk — how  much  of  them  are  absorbed  and  exactly 
how  much  rejected  by  the  intestine.  It  has  been  intimated  in  an- 
other paragraph  that  the  heating  of  the  milk  causes  a  complete  loss 


138 


NUTBIIION  AND  INFANT  FEEDING. 


to  the  economy  of  the  salts  present  in  cows'  milk ;  but  inasmuch  as  the 
heating  of  milk  is  coming  more  and  more  into  disuse,  and  more  pro- 
nounced efforts  are  being  made  to  obtain  a  pure  milk  which  can  be 
administered  with  as  little  heating  as  possible,  we  have  still  to  learn 
the  fate  of  the  salts  in  sterilized.  Pasteurized,  or  raw  milk,  and  the 
indications  for  adding  equivalents  of  soluble  salts  to  the  milk  for  the 
feeding  of  infants. 


A  Schedule  of  Percentages  Adapted  to  Infants  of  Various  Ages. 


Age. 

Proteids. 

Fat. 

Sugar. 

Premature  infants . 

One  to  seven  days 

Seven  to  fourteen  days 

Fourteen  to  thirty  days 

One  to  three  months 

Three  to  six  months 

Six  to  nine  months 

Nine  to  twelve  months 

Per  cent. 
0.33 
0.50 
0.80 
1.00 
1.25 
1.50 

1.50  to  2.00 
3.05 

Per  cent. 
1.00 
1.50 
2.50 
3.00 
3.75 

3.00  to  4.00 
3.00  to  4.00 
4.00 

Per  cent. 
5  to  6 
5  to  6 
5  to  6 
5  to  6 
5  to  6 
5  to  6 
5  to  6 
5  to  6 

Number  of  Nursings,  with  the  Quantity  of  Milk  Necessary  for 
the  Infant. — The  quantity  of  milk  which  should  be  given  to  the 
infant  at  each  feeding  from  birth  to  the  ninth  month  has  been 
variously  estimated.  The  capacity  of  the  stoinach  alone  would  be  a 
crude  and  most  unscientific  standard,  for  this  would  not,  in  artificial 
feeding  at  least,  follow  nature's  method  with  breast-feeding,  for  from 
birth  the  amount  of  milk  furnished  to  the  infant  by  the  human 
breast  daily  does  not  always  accord  with  the  full  capacity  of  the 
infant's  stomach.  It  will  be  found  that  the  quantity  fed  to  the 
breast-fed  infant  is  much  below  the  stomach  capacity  if  the  infant  is 
fed  at  frequent  intervals,  and,  as  has  been  shown  in  Ahlfeld's  baby, 
equal  to  or  even  above  it  if  nursed  at  long  intervals.  With  artificial 
feeding,  moreover,  we  know  that  there  is  a  great  waste  in  feeding 
infants  upon  cows'  milk,  and  were  an  infant  fed  on  exactly  the  same 
amounts  of  modified  cows'  milk  as  some  of  the  breast-fed  infants 
obtain  from  the  breast,  it  would  not  increase  regularly  in  weight  and 
might  even  starve. 

The  age  of  the  infant,  also,  is  not  a  guide,  for  what  would  be 
a  suflBcient  amount  for  one  infant  might  not  be  sufiicient  for  an- 
other, or  might  be  even  an  excess.  In  all  cases  the  capacity  of 
digestion  must  be  taken  into  account,  and  also  the  development  of 
the  child.  Some  vigorous  infants  will  take  more  food  than  other 
infants  of  the  same  age  that  are  not  as  well  developed  physically. 
More  rational  is  the  method  of  arriving  at  the  amount  to  be  given 
at  each  feeding  which  takes  into  consideration  not  only  the  capacity 


ARTIFICIAL  FEEDING  OF  INFANTS.  139 

of  the  stomacli,  but  the  age  and  the  amount  of  primary  food  ele- 
ments necessary  to  maintain  nutrition  and  to  increase  body-weight 
of  the  infant  at  various  ages.  If  we  calculate  the  amount  of 
albumin  or  proteids  or  fat  necessary  per  kilogramme  of  the  body- 
weight  to  maintain  nutrition,  we  shall  have  the  more  scientific 
method  of  determining  the  quantity  of  milk  to  be  taken  daily  by 
the  infant.  This  method  has  been  advocated  by  Huebner  and  Kubner 
and  also  Escherich. 

The  difficulty  of  calculating  what  is  known  as  the  calories  neces- 
sary to  the  maintenance  of  nutrition  and  body-weight — and  by  calories 
is  meant  the  amount  of  albumin  or  proteids,  fat,  salts,  and  water 
mentioned  above — is,  that  the  physician  cannot  always  have  at  his 
disposal  a  method  by  which  these  calculations  can  be  made.  In 
other  words,  they  must  rely  on  investigations  made  by  others,  and 
understand  that  the  results  as  they  are  presented  to  us  to-day  in 
infant-feeding  are  based  on  actual  calculations  of  the  amount  of 
calories  necessary  to  the  infant.  It  has  been  found  that  the  nutrition 
of  artificially  fed  infants  cannot  be  maintained  by  an  amount  ol 
proteid  of  cows'  milk  equal  to  that  taken  in  the  breast  milk.  In  other 
words,  the  proteid  equivalent  can  be  obtained,  but  other  constituents, 
such  as  fat,  would  be  at  fault,  as  well  as  the  daily  quantity  of  food, 
were  we  to  depend  entirely  upon  the  caloric  method.  The  figures 
given  to  the  student  and  physician  to-day,  therefore,  are  a  combination 
of  what  has  been  found  empirically  to  be  needed,  and  what  has  been 
verified  in  the  chemical  laboratory  to  be  absolutely  necessary.  Let 
the  student  therefore  study  the  amount  of  breast  milk  consumed  by 
the  infant  in  the  twenty-four  hours,  and  compare  these  amounts  with 
the  amounts  consumed  by  the  bottle-fed  infant  in  the  same  period  of 
time. 

Number  of  Nursings  Daily  and  Quantity  of  Each  Feeding  for 
the  Artificially  Fed  Infant. — If  we  now  attempt  to  apply  the  knowl- 
edge acquired  in  the  study  of  the  breast-fed  infant  to  the  artifi- 
cially fed  infant  we  meet  with  the  following  obstacles :  Cows'  milk 
taken  in  the  same  quantities,  as  has  been  said,  is  not  as  completely 
used  up  by  the  gut  as  breast  milk.  There  is  much  more  waste, 
as  has  been  shown  by  Knopfelmacher  and  Camerer.  This  waste  is 
caused  chiefly  by  the  failure  of  the  gut  to  assimilate  completely 
the  casein  and  the  fat  of  the  cows'  milk.  The  stools,  also,  of  bottle- 
fed  infants  are  more  numerous  and  of  greater  total  bulk  than  those 
of  breast-fed  infants.  In  view  of  the  lack  of  definite  knowledge 
on  all  these  points,  the  quantities  of  modified  cows'  milk  which 
should  be  given  at  each  feeding  to  the  infant  are  still,  as  has  been 
intimated,  only  approximate.  The  amount  of  calories  necessary  for 
the  maintenance  of  nutrition  and  a  definite  increase  of  the  body- 


140 


NUTRITION  AND  INFANT  FEEDING. 


weight  will  be  shown  elsewhere,  and  the  student  may  compare  the 
tables  given  with  the  equivalent  calories  in  the  total  amount  of  breast 
milk  and  cows'  milk  given  to  the  breast-fed  or  artificially  fed  infant. 
He  can  therefore  satisfy  himself  of  this  fact  that  the  older  authors, 
and  even  some  of  the  most  recent  writers,  underfeed  their  infants,  if 
the  food  which  they  prescribe  is  strictly  adhered  to  in  quantity  and 
composition;  and  such  is  the  fact,  for  many  of  these  infants  I  found 
by  observation  not  only  to  be  underweight,  but  in  some  cases  they 
fail  in  complete  assimilation  of  their  foods.  The  physician  must  also 
understand,  however,  that  only  a  few  of  these  formulae  and  state- 
ments really  epitomize  the  limit  of  our  knowledge  to-day,  and  future 
investigators  must  complete  that  knowledge. 

Table  Showing  the  Number  of  Feedings  and  Quantities  of  Modified 
Milk  to  be   Given  to  Artificially  Fed  Infants. 


Age. 


First  day 

Second  day 

Third  day 

Fourth  day 

Seventh  day        

Second  week        

Fourth  week  or  first  month  . 

Two  months 

Three  months 

Four  months 

Five  months 

Six  months 

Seven  and  eight  months    .    . 
Nine  months 


Number  of  feed- 
ings daily. 


8-10 
8-10 
8-9 
7  or  8 

7 

7 
6  or  7 

6 

6 

6 


Quantity  at  eacli 

feeding. 

Co. 

Oz. 

10 

20 

30 

1 

40 

50 

60 

2 

60 

2 

90 

3 

120 

4 

150 

5 

180 

6 

210 

7 

240 

8 

250 

8^ 

Total  to  be  given 
in  24  hours. 


C.c. 
30 

160 

240 

320 

400 

480 

480 

630-720 

840 
1050 

1080-1260 
1260 
1440 
1500 


Oz. 

1 

5^ 

8 
lOf 
13^ 
16 
16 

21-24 
28 
35 

36-42 
42 
48 
50 


The  increase  in  the  amount  of  milk  from  the  seventh  to  the  ninth 
month  is  not  so  apparent,  since  at  this  period  we,  as  a  rule,  begin  to 
feed  cereals  in  addition  to  the  milk. 

The  above  figures  are  not  absolute,  but  only  approximate.  Some 
infants  may  require  a  half-ounce  or  more  than  the  quantities  indi- 
cated ;  others  will  be  satisfied  with  less  nursings.  In  all  these  items 
an  observant  student  of  the  infant  will,  guided  by  the  observations  of 
the  nurse  of  the  infant,  discover  the  indications  in  each  case  for 
himself. 

Household  Modification  of  Milk  for  Infant-feeding. — The  accu- 
racy obtained  in  home  modification  is  as  well  adapted  to  the  feeding 
of  infants  as  the  laboratory  percentages.  The  advantages  of  home 
modification  of  cows'  milk  for  infant-feeding  may  be  stated  briefly 
as  follows :  The  family  and  the  physician  can  be  independent  of  the 
modifier  at  the  laboratory.     The  milk  is  manipulated  as  little  as 


ARTIFICIAL  FEEDING  OF  INFANTS. 


141 


possible.     If  the  infant  does  not  thrive,  we  can  say  definitely  what 
is  at  fault. 

The  home  modification  of  milk  for  infant-feeding  depends  on  the 
fact  that  in  large  cities,  and  in  places  where  milk  is  obtainable  from 
the  dairy  within  a  reasonable  time,  the  milk  can  be  separated  by 
gravity  into  top  milk  or  cream  and  skim  milk,  and  this  separation 
takes  place  in  certain  definite  proportions.  Meigs,  Biedert,  and 
Chapin  showed  that  it  is  possible  to  construct  from  top  milk  per- 
centage mixtures,  inasmuch  as  the  top  milk  prepared  in  the  manner 
to  be  described  has  an  average  constant  percentage  of  fat,  proteids, 
and  sugar. 


QUART  BOTTLE  OF  MILK 
BEFORE  CREAM  HAS  RISEN 


Tig.  25. 

QUART  BOTTLE  OF  MILK      FAT  IN  different  portions 
AFTER  CREAM  HAS  RISEN       removed  from  the  top 

AND  MIXED. 


GRAVITY  CREAM 

CONTAINS  m  to  24,".  FAT 


FAT  3^  TO  5j« 

PROTEIDS    3^T0  4i{ 
SUGAR  4^  TO  6^ 


FAT  AND  PROTEIDS  ARE 

NEARLY  EQUAL  EXCEPT  IN 

VERY  RICH  MILKS 


TOP   2  OZS.  MIXED  24)<  FAT 


REMAINING  MILK 

OR 

SKIM  MILK 

FAT  .Zf,  TO  1.Bi< 

PROTEIDS    3i«T0  4iS 
SUGAR  4^  TO  6^ 


'      3  OZS.      " 

22.5je  " 

'      4  OZS.     •' 

2\Ai  " 

5  OZS.     " 

19.2!<" 

6  OZS.     " 

16.8^" 

7  OZS.      " 

8  OZS.      " 

9  OZS.      " 
10  OZS.     " 

1B.0;<" 
13.3;S" 
11.5:«  " 

io.5;s " 

12  OZS.      " 

9.0^" 

14  OZS.      " 

7.8^" 

16  OZS.     " 

7.0i«-' 

18  OZS.      " 

6.3;J" 

20  OZS.     " 

B.0;2" 

22  OZS.      " 

5.4:^  " 

24  OZS.      " 

B.0;8  *• 

26  OZS.      •• 

4.7^  " 

28  OZS.      " 

4.B^  " 

30  OZS.      " 

4.3f,  " 

ALL  MIXED 

AM  " 

Diagram  illustrating  the  formation  of  top  milks  in  quart  bottles,  so-called  setting  process. 
Modified  from  the  diagrams  of  Chapin. 

Top  Milk. — In  this  country  the  custom  of  delivering  milk  in 
so-called  quart  bottles  is  almost  universal.  The  milk  is  placed  in 
these  bottles  at  the  dairies,  and  when  it  reaches  the  consumer,  it  is 
set,  as  it  is  termed,  into  a  top  creamy  layer  above,  and  a  milk  poor 
in  fat,  so-called  skim  milk,  below  (Fig.  25). 

In  the  supernatant  creamy  fluid,  or  top  milk,  we  find  certain 
definite  percentages  of  fat.     In  modifying  milk  in  the  home,  the  top 


142  NUTBITION  AND  INFANT  FEEDING. 

lajer  as  it  separates  from  the  milk  is  utilized  as  it  is  delivered  in 
quart  bottles.  Chapin  has  found  that  if  a  number  of  milks  deliv- 
ered in  the  citv  homes  are  analyzed,  the  first  9  ounces  from  the  top 
of  the  quart  bottle  of  milk  will  contain  all  the  way  from  12  to  16 
per  cent,  of  fat,  varying  with  the  richness  of  the  milk  in  fat. 

Twelve  Per  Cent.  Top  Milk. — If  the  original  milk  contains  4  per 
cent,  of  fat,  the  first  9  ounces  will  be  what  is  known  as  a  12  per 
cent,  top  cream.  If  the  milk  is  a  very  rich  milk  containing  butter 
fat  to  the  extent  of  5  per  cent.,  the  top  9  ounces  will  contain  16  per 
cent.,  approximately,  of  fat.  The  proteids  are  quite  constant  in  the 
top  milk  and  are  equal  to  those  found  in  the  skimmed  milk.  In 
other  words,  in  milk  rich  in  butter  fats  the  top  milk  contains  fat  in 
proportion  to  the  proteids  of  3  to  1.  If  the  milk  is  poor  and  only 
contains  3  per  cent,  of  butter  fat,  the  first  9  ounces  will  contain 
generally  9  per  cent,  of  fat,  and  this  milk  will  contain  3  per  cent,  of 
proteids,  so  that  the  percentage  of  fat  to  proteids  still  remains  3  to  1. 
It  may  be  said  at  the  start  that  the  student  would  do  well  not  to 
consider  the  thin  milk  as  existent,  for  most  milk,  either  in  the  city  or 
throughout  the  country,  contains  at  least  4  per  cent,  of  butter  fat. 

Seven  Per  Cent.  Top  Milk.^ — Another  top  milk  to  be  considered  is 
the  so-called  first  16  ounces  taken  from  a  quart  of  milk.  If  the  milk 
is  a  rich  milk  and  contains  5  per  cent,  of  butter  fat,  the  first  16  ounces 
will  contain  9  per  cent,  of  fat.  If  it  contains  4  per  cent,  of  butter 
fat,  the  first  16  ounces  will  contain  7  or  8  per  cent,  of  fat.  The  fat 
in  both  of  these  instances  is  present  in  a  proportion  of  2  to  1,  as  com- 
pared to  the  proteids.  The  physician  would  do  well  to  assume  in 
making  his  modifications  that  he  is  dealing  with  a  rich  milk.  In 
this  way  he  will  avoid  giving  mixtures  which  contain  too  much  fat, 
which  element  gives  the  most  trouble  if  present  in  too  great  quantity. 
If  the  student  will  therefore  simply  consider  the  top  9  and  16  ounces 
of  rich  milk,  he  will  have  sufiicient  material  for  feeding  the  infant 
up  to  the  ninth  month  of  infancy.  He  should  therefore  try  to  per- 
fect himself  in  the  methods  of  utilizing  top  milk  in  which  the  fat 
is  present,  as  compared  to  the  proteids,  in  the  proportion  of  3  to  1, 
and  a  more  dilute  top  milk  in  which  the  fat  is  present,  as  compared 
to  the  proteids,  in  the  proportion  of  2  to  1. 

In  feeding  infants  up  to  the  third  month  it  is  convenient  to  use  a 
top  milk  in  which  the  fat  is  present,  as  compared  to  the  proteids,  in 
the  proportion  of  3  to  1.  In  other  words,  it  is  best  to  use  the  first 
9  ounces  of  top  milk,  for  by  this  method  we  can  obtain,  as  will  be 
shown  by  the  tables,  a  smaller  percentage  of  proteids  and  the  requisite 
percentage  of  fat  indicated  in  the  earlier  periods  of  infancy.  From 
the  third  to  the  sixth  month  it  is  advisable  to  use  a  top  milk  in  which 
the  fat  is  present,  as  compared  to  the  proteids,  in  the  proportion  of 


ARTIFICIAL  FEEDING  OF  INFANTS.  143 

2  to  1,  for  in  this  way  we  can  obtain  a  larger  percentage  of  proteids 
and  more  fat  from  one  bottle  of  milk  than  we  could  if  we  use  a 
smaller  amount  of  richer  top  milk  in  which  the  fat  is  present,  as 
compared  to  the  proteids,  in  the  proportion  of  3  to  1,  for  in  the  latter 
case  we  shall  be  compelled  to  use  2  bottles  of  milk.  This  can  more 
readily  be  understood  by  reading  the  subjoined  tables  indicating  the 
percentages  at  the  various  ages. 

Chapin,  for  the  purpose  of  obtaining  the  top  milk,  has  devised  a 
small  dipper.  The  use  of  the  dipper  is  convenient  but  not  necessarily 
essential.  If  the  top  milk  is  poured  off  carefully,  equal  accuracy  is 
obtainable  without  the  use  of  the  dipper. 

Top  Milk  Made  at  Home.^ — In  cities  milk  is  delivered  in  quart 
bottles,  and  in  many  places  in  the  country  this  is  also  the  case.  But 
if  the  practitioner  is  living  in  a  district  where  bottled  milk  is  not 
sold  or  not  obtainable,  it  is  quite  necessary  that  he  should  understand 
that  there  is  no  mystery  about  bottled  milk.  Any  milk  obtained 
shortly  after  milking  and  placed  in  a  wide-necked  bottle  or  utensil 
with  a  capacity  of  one  quart  will  separate  the  top  milk,  or  set,  as  it 
is  called,  in  the  manner  previously  described  under  the  heading  of 
Top  Milk.  This  setting  process  takes  place  within  four  hours  after 
the  milk  is  placed  in  the  utensil,  so  that,  if  the  practitioner  has  not 
access  to  bottled  milk,  he  can  be  accurate  if  he  will  obtain  an  ordinary 
quart  utensil,  such  as  a  pitcher,  and  place  the  milk  in  the  same  as 
soon  after  the  milking  as  possible,  setting  it  aside  for  four  to  six 
hours,  and  then  proceeding  according  to  directions  given.  Such  milk 
will  show  the  separation  into  the  skim  milk  and  creamy  layer,  as 
described  elsewhere. 

There  should  be  no  visible  dirt  or  dark  specks  in  the  bottom  of  the 
bottle,  for  such  milk  is  unwholesome  and  should  not  be  given  to  the 
infant.  The  milk  should  have  no  peculiar  odor,  for  no  matter  how 
carefully  modified,  such  milk  will  be  rejected  by  the  infant.  If 
mixed  with  equal  portions  of  TO  per  cent,  alcohol,  milk  when  heated 
in  a  test-tube  should  not  curdle.  In  other  words,  we  should  begin 
with  a  good,  fresh,  clean  milk. 

The  Home  Preparation  or  Modification  of  Milk  for  Infant- 
feeding.- — In  what  follows  it  must  not  be  forgotten  that  the  formulse 
and  statements  are  directed  toward  the  management  of  distinctly  nor- 
mal cases.  We  will  consider  the  percentage  modification  of  cows' 
milk  in  the  household,  presupposing  that  there  are  no  difficulties  in 
the  way  of  complete  assimilation  by  the  infant. 

The  Method  of  Calculating  Percentages.^ — Taking  the  milk  in 
quart  bottles  as  a  standard  we  know  that  in  the  first  9  ounces  of  top 
milk  the  ratio  of  fat  to  proteids  is  as  3  to  1,  and  in  calculating  any 
percentages,  whether  we  fix  on  the  proteids  or  on  the  fats  as  a  method 


144  NUTRITION  AND  INFANT  FEEDING. 

of  calculation  makes  very  little  difference,  provided  we  remember 
this  proportion.  For  example:  If  we  calculate  on  a  formula  con- 
taining 3  per  cent,  of  fat,  and  we  desire  to  construct  this  formula 
with  the  first  9  ounces  of  top  milk,  the  proteids  in  that  formula  will 
be  1  per  cent.  If  we  wish  to  give  0.25  per  cent,  proteids  from  the 
first  9  ounces  of  top  milk,  the  fat  must  necessarily  exist  in  a  per- 
centage of  0.75.  It  is  well,  therefore,  for  the  practitioner  simply  to 
fix  in  his  mind  what  percentage  of  one  or  the  other  ingredient  he 
desires  to  give  to  the  infant,  calculate  upon  that,  and  the  fat  or  pro- 
teid  will  exist  in  that  formula  in  the  ratio  indicated.  The  author, 
for  convenience,  fixes  the  amount  of  proteid  which  he  wishes  in  his 
mixture,  multiplies  that  by  3,  to  obtain  the  percentage  of  fat  that 
would  exist  in  that  mixture,  and  proceeds  in  the  following  way :  An 
infant  at  birth,  for  example,  will  receive  0.5  per  cent,  of  proteids,  its 
■fats  would  be  1.5  per  cent.,  if  constructed  from  the  first  9  ounces  of 
top  milk. 

Let  us  suppose,  for  example,  that  a  12  per  cent,  top  milk  is  to  be 
used,  and  that  the  total  amount  to  be  given  in  twenty-four  hours  is 
8  ounces.  We  wish  to  reduce  the  percentage  to  1.5.  The  question 
involved  is,  "  How  much  of  the  12  per  cent,  top  milk  must  be  used 
to  make  a  1.5  per  cent.  8-ounce  mixture?"  The  following  mathe- 
matical statement  simplifies  the  process : 

If  of  a  12  per  cent,  top  milk  you  would  use  8  ounces  in  twenty- 
four  hours,  to  make  a  1  per  cent,  top  milk  you  would  use  xV  of  8, 
equal  f  ounces.  To  make  a  1.5  per  cent,  top  milk  you  would  use 
1.5  times  f ,  equal  1  ounce. 

One  ounce,  then,  of  a  12  per  cent,  top  milk,  diluted  7  times,  will 
give  an  8-ounce  1.5  per  cent,  mixture. 

How  to  Work  Out  the  Above  Percentages  of  Fat,  Proteids,  and  Sugar. 
— Problem  1. — Let  the  physician  take,  for  example,  a  premature 
infant.  By  referring  to  the  schedules  it  is  seen  that  such  an  infant 
should  have  10  or  12  feedings  in  the  twenty-four  hours.  The  most 
assimilable  mixture  should  have  a  strength  of  0.33  per  cent,  proteids, 
1  per  cent,  of  fat,  and  5  or  6  per  cent,  of  sugar.  Such  an  infant 
should  have  12  feedings,  each  \  ounce,  making  a  total  of  6  ounces 
for  the  twenty-four  hours.  If  a  12  per  cent,  top  milk  is  utilized, 
inasmuch  as  the  fat-percentage  of  our  mixture  is  1  and  that  of  our 
top  milk  is  12,  the  total  quantity  in  the  twenty-four  hours  being  6 
ounces,  we  need  tV  of  6,  equal  -J  ounce  of  this  12  per  cent,  top  milk, 
which  must  be  diluted  by  5-J-  ounces  of  water  or  barley-water,  as  the 
case  requires,  in  order  to  obtain  a  mixture  of  6  ounces  containing  1 
per  cent,  of  fat. 

In  order  to  get  the  requisite  percentage  of  sugar  of  milk  which, 
when  mingled  with  the  diluent  and  the  -2-  ounce  of  top  milk,  will 


ARTIFICIAL  FEEDING  OF  INFANTS.  145 

approximate  5  per  cent.,  2  teaspoonfuls  of  sugar  of  milk  should  be 
dissolved  in  the  diluent  before  adding  the  top  milk. 

Problem  2. — The  infant  is  one  month  old.  Such  an  infant  would 
assimilate  best  a  mixture  apj)roximating  1  per  cent,  of  proteids,  3 
per  cent,  of  fat,  and  5  per  cent,  of  sugar.  It  would  need  10  feedings 
in  the  twenty-four  hours,  each  containing  2^  ounces,  making  a  total 
quantity  of  25  ounces.  If  the  9-ounce  top  milk  is  used  (12  per  cent, 
of  fat)  we  would  proceed  as  follows :  The  percentage  of  fat  desired 
being  3,  and  the  total  daily  quantity  being  25  ounces,  we  would  have 
to  take  \2,  of  25,  equal  to  ^\  ounces  of  12  per  cent,  top  milk,  with 
18f  ounces  of  the  diluent,  which  should  contain  6  per  cent.,  of  milk- 
sugar,  or  Y  teaspoonfuls. 

Problem  S. — The  infant  is  four  months  old,  and  it  is  desirable 
to  construct  its  formula  from  the  16-ounce  top  milk  (7  per  cent, 
fat),  ratio  of  fats  to  proteids  2  to  1.  The  percentages  most  adapted 
at  this  age  would  be  3  of  fat,  1.5  of  proteids,  and  5  of  sugar  of  milk. 
This  infant  should  have  8  feedings  in  the  twenty-four  hours,  each 
containing  5  ounces,  a  total  of  40  ounces  of  food  in  the  twenty-four 
hours.  The  percentage  of  fat  being  3,  that  of  the  top  milk  Y,  and 
the  total  amount  of  food  being  40  ounces,  there  would  be  needed  %  of 
40,  equal  to  17  ounces  of  top  milk,  with  23  ounces  of  the  diluent,  to 
which  is  added  6  per  cent,  of  milk-sugar,  or  9  teaspoonfuls. 

For  the  above  formula  it  will  be  necessary  to  use  2  bottles  of  milk, 
taking  16  ounces  off  each,  mixing  them  together,  and  of  these  32 
ounces  to  utilize  17. 

Problem  Jf. — The  infant  is  six  months  of  age,  and  would  need  7 
feedings,  of  7  ounces  each,  making  a  total  of  49  ounces  for  the  twenty- 
four  hours.  The  formula  most  adapted  in  this  case  would  be  3  per 
cent,  of  fat,  1.5  per  cent,  of  proteids,  and  5  per  cent,  of  sugar  of 
milk,  utilizing  the  top  16  ounces  of  a  bottle  of  milk,  the  percentage 
of  fat  in  the  formula  being  3,  that  of  the  top  milk  7,  and  the  total 
amount  of  the  food  being  49  ounces,  there  would  be  needed  %  of  49, 
equal  to  21  ounces  of  top  milk ;  28  ounces  of  the  diluent  will  be  neces- 
sary, containing  5  per  cent,  of  milk-sugar,  or  9  teaspoonfuls. 

It  will  be  necessary  in  this  case,  also,  to  utilize  two  quart  bottles 
of  milk  to  obtain  21  ounces  of  16-ounce  or  7  per  cent,  top  milk. 
That  is,  32  ounces  of  this  top  milk  are  obtained,  and  of  these  21 
ounces  only  are  utilized. 

Problem  5. — The  infant  is  nine  months  of  age.  In  this  case  6 
feedings  will  be  given  in  the  twenty-four  hours,  each  containing  8 
ounces,  making  a  total  of  48  ounces.  The  formula  most  adapted  to 
this  age  would  be  4  per  cent,  of  fat,  2  per  cent,  of  proteids,  and  5  per 
cent,  of  milk-sugar.  The  percentage  of  fat  being  4  in  the  formula, 
that  of  the  top  milk  7,  and  the  total  quantity  of  food  for  the  twenty- 

10 


146        '  NUTEITION  AND  INFANT  FEEDING. 

four  hoiTrs  being  48  ounces,  the  physician  -would  need  tr  of  48,  equal 
to  25  ounces  of  7  per  cent,  or  16-ounce  top  milk,  23  ounces  of  the 
diluent,  and  enough  sugar  of  milk  to  make  a  5  per  cent,  solution. 

Problem  6. — An  infant  six  months  of  age,  for  therapeutical  rea- 
sons, is  to  be  put  on  a  formula  containing  1.5  per  cent,  of  fat,  0.5 
per  cent,  of  proteids,  and  5  per  cent,  of  sugar.  Here  the  percentage 
of  fats  to  the  proteids  is  as  3  to  1,  therefore  it  will  be  convenient  to 
use  the  top  milk  containing  10  to  12  per  cent,  of  fat  and  3.5  per  cent, 
of  proteids.  It  is  desired  to  give  the  infant  7  feedings  of  7  ounces 
each,  making  a  total  of  49  ounces.  The  percentage  of  fat  being  1.5 
in  the  formula,  and  that  of  the  top  milk  being  12,  the  total  quantity 
for  the  twenty-four  hours  being  49  ounces,  the  physician  would  need 

1.5 

—^ —  of  49,  equal  to  6^  ounces  of  top  milk,  42|-  ounces  of  the  diluent. 

In  order  to  get  a  5  per  cent,  solution  of  the  milk-sugar  there  would  be 
needed  in  this  case  5  per  cent,  of  42  ounces,  equal  to  18  teaspoonfuls 
of  the  milk-sugar. 

It  frequently  happens  with  infants  above  three  months  of  age 
taking  a  modification  of  the  16-ounce  top  milk  that  constipation  will 
set  in,  and  we  wish  to  increase  the  fats  in  order  that  the  movements 
may  be  less  constipated.  In  order  to  do  this  we  must  obtain,  a  top 
milk  which  is  richer  in  fat  than  the  top  milk  we  are  giving.  To 
illustrate:  The  infant  who  is  taking  a  third  dilution  of  the  16-ouuce 
top  milk  will  be  taking  approximately  2.5  per  cent,  of  fat,  1.2  to  1.5 
per  cent,  of  proteids.  If  we  wish  to  increase  the  fats  to  4  or  3.5  per 
cent,  and  retain  the  proteids  we  are  administering  to  the  infant,  it 
will  be  impossible  to  do  this  with  the  16-ounce  top  milk,  for  any 
dilution  of  this  milk  will  vary  the  proteids.  We  are  therefore  com- 
pelled to  resort  to  the  utilization  for  such  an  infant  of  the  9-ounce  top 
milk,  which  contains  an  average  of  10  to  12  per  cent,  of  fat.  By 
diluting  this  one-third  we  would  get  about  3.5  to  4  per  cent,  of  fat  and 
still  retain  the  same  percentage  of  proteids  as  in  our  original  mixture. 

An  infant  four  months  of  age,  taking  eight  bottles,  5  ounces  each, 
would  need  40  ounces  for  its  daily  mixture.  TTe  would  therefore  be 
compelled  to  use,  in  order  to  obtain  the  9-ounce  top  milk,  2  quarts  of 
milk,  from  each  of  which  9  ounces  would  be  taken,  making  18  ounces 
of  top  milk.  This,  after  being  thoroughly  mixed,  would  be  utilized 
to  the  extent  of  13  ounces  for  our  mixture,  giving  27  ounces  of  the 
diluent,  whatever  that  may  be,  we  would  have  a  formula  of  3.5  per 
cent,  fat,  1.3  to  1.5  per  cent,  proteids. 

It  should  be  understood  that  the  percentages  of  fats  given  in  these 
tables  are  only  approximate,  for  there  is  no  milk  which  will  yield  an 
absolute  fixed  percentage  of  fat  in  the  top  milk  obtained  by  gravity, 
without  variation,   from  day  to   day.     The   proteids,   however,   are 


ARTIFICIAL  FEEDING  OF  INFANTS.  147 

more  constant  in  percentage;  but  even  here  in  modificatioiL  we  can 
only  obtain  approximate  accuracy.  Though  these  tables  contain  8 
modifications  each,  some  of  them  differing  but  ^  of  1.  per  cent,  either 
in  the  fats  or  the  proteids,  such  minutiae  are  not  really  needed  or  even 

Formulce  constructed  with  top  9-ounce  milk,  having  an  average 
composition  of  12  per  cent,  fat,  3.5  per  cent,  proteids,  4  per  cent, 
sugar.     Possible  combinations. 


Fat. 

Proteid. 

Su 

gar. 

1.00  per  cent. 

0.33  pe 

r  cent. 

5  pel 

•  cent. 

1.50        " 

0.50 

5 

2.00        " 

0.66 

5 

2.50       " 

0.83 

5 

3.00       " 

1.00 

5 

3.50       " 

1.20 

5 

4.00       " 

1.33 

5 

4.50       " 

1.50 

5 

Formulce  constructed  with  top  IQ-ounce  milk,  having  an  average 
composition  of  7  per  cent,  fat,  3.5  per  cent,  proteids,  4  per  cent,  sugar. 
Fats  to  proteids  2  to  1.     Possible  combinations. 


Fat. 

1.00 

per  cent. 

1.50 

2.00 

2.50 

3.00 

3.50 

4.00 

Proteid. 

Sugar. 

0.50  per  cent. 

5  per  cent. 

0.75      " 

5 

1.00      " 

5 

1.25       " 

5 

1.50      " 

5 

1.75       " 

5 

2.00       " 

5 

Whole  milk  having  an  average  composition  of  4  per  cent,  fat,  3.5 
per  cent,  proteids,  4  per  cent,  sugar.  Fats  to  proteids  S  to  7.  Pos- 
sible combinations. 


Fat. 

Proteid. 

Sugar. 

1.00 

per  cent. 

0.85  per  cent. 

5  per  cent. 

1.50 

1.32       " 

5 

2.00 

1.60       " 

5        " 

2.50 

2.15       " 

5 

3.00 

2.60       " 

5 

3.50 

3.00        " 

5        " 

4.00 

3.50      " 

5 

possible  in  practice.  It  will  be  found  best  to  master  3  or  4  modifica- 
tions of  top  milk,  constructed  either  from  the  9-ounce  top  milk  or  the 
16-ounce  top  milk,  and  utilize  these  in  general  practice.  For  exam- 
ple: The  infant  who  is  taking  1  per  cent,  of  fat  and  1.33  per  cent, 
of  proteids  may  do  just  as  well  on  1.2  per  cent,  of  fat  and  1.50  per 
cent,  of  proteids.  For  all  practical  purposes,  therefore,  formulae 
which  contain  1.5,  2.5,  and  3.5  per  cent,  of  fat  will  be  as  available  in 
practice  as  formulae  containing  1,  2,  and  3  per  cent,  of  fat. 

Referring  to  the  proteid  percentages,  it  will  be  seen  that  certain 


148  NUTRITION  AND  INFANT  FEEDING. 

of  them  are  in  heavy-faced  type.  Both  in  the  laboratory  and  at  home 
it  is  impossible  to  obtain  an  accuracy  which  will  assure  the  physician 
that  he  is  administering  to  his  patient  0.66  and  not  0.5  per  cent,  of 
proteids,  or  some  intermediate  figure ;  nor  can  he  be  certain  that  his 
mixture,  even  if  prepared  at  the  laboratory,  contains  1.23  or  1.33 
per  cent,  of  proteids,  rather  than  some  slightly  higher  or  lower  figure. 
The  reason  for  this  is  that  the  proteids  of  cows'  milk,  like  the  fats, 
must  vary  from  day  to  day,  and  thus  no  absolute  fixed  average  per- 
centage of  proteids  can  be  counted  on. 

Konig,  in  an  analysis  of  several  hundreds  of  milks  obtained  from 
a  number  of  herds  of  cows,  shows  that  the  proteid  percentages  in  milk 
vary,  not  only  at  different  seasons  of  the  year,  but  at  times  of  the  day, 
and  also  with  different  kinds  of  fodder.  It  is  therefore  illogical  to 
attempt  the  working  out  of  minutise  of  percentages  varying  from  0.2 
to  0.3,  when  the  original  milk  has  not  a  fixed  average  percentage. 
To  obtain  accuracy  within  the  difference  between  0.2  to  0.3  per  cent, 
would  necessitate  a  chemical  analysis  of  the  milk  before  each  modifi- 
cation is  made,  a  manifestly  impracticable  procedure,  especially  as 
regards  the  proteids  in  the  milk.  The  author  has  gone  into  these 
matters  to  show  that  the  elaborate  tables  given  by  some  are,  on  careful 
analysis,  impracticable.  It  is  well,  therefore,  for  the  physician  to 
feel  assured  that  with  the  proteids,  as  with  the  fats,  approximate 
formulae  with  averages  of  0.25,  0.5,  1,  1.5,  2,  and  2.5  per  cent,  of 
proteids  are  as  effective  in  practice  as  minute  fractional  percentages, 
if  such  were  attainable. 

Too  High  Fat-percentages  and  Their  Remedy. — If  Problem  4 
is  studied  it  will  be  seen  that  2  bottles  of  milk  must  be  utilized  in 
order  to  obtain  the  requisite  21  ounces  of  top  milk,  and  if  this  is  so 
for  the  sixth  month,  more  of  this  top  milk  will  be  required  for  the 
seventh  and  eighth  months.  Some  infants  will  not  thrive  on  such  a 
large  amount  of  fat.  In  the  summer  especially  they  will  spit  uj), 
and  have  several  loose  movements  dail}^  Or  they  become  anremic 
and  constipated,  with  dry,  soapy  movements.  In  the  face  of  such 
difficulties  I  follow  the  plan  of  using  only  1  bottle  of  milk ;  and,  if 
after  the  fifth  month  (Problem  3)  more  than  16  ounces  of  top  milk 
are  required,  I  take  these  off  the  top  of  the  bottle,  adding  the  rest  as 
diluent.  Thus,  at  the  sixth  month,  21  ounces  off  the  top  of  a  quart 
of  milk  to  28  ounces  of  diluent.  At  the  seventh  month,  23  ounces  off 
the  top  of  a  quart  of  milk  to  the  required  amount  of  diluent.  At  the 
eighth  month,  25  ounces  off  the  top  of  a  quart  of  milk  to  the  required 
amount  of  diluent.  The  amount  of  diluent  is  calculated  as  in  the 
foi'iiici'  tables. 

By  this  iiictliod  of  simply  increasing  the  amount  of  milk  taken 
off  the  top  of  one  <|iiai't  of  milk  after  the  sixth  month,  we  arrive  at  a 


ARTIFICIAL  FEEDING  OF  INFANTS.  149 

point  (the  tenth  or  eleventh  month)  when  the  infant  is  taking  a  full 
quart  of  milk  with  diluent  daily.  This  method,  which  is  exceedingly 
simple,  and  which  in  summer  particularly  does  away  with  the  danger 
of  excess  of  fats,  has  served  me  well. 

If  this  method  is  pursued,  the  strict  calculation  of  percentages  of 
fats  and  proteids  is  necessarily  abandoned. 

Problem  7. — Let  us  suppose  that  for  certain  reasons  top  milk 
cannot  be  obtained,  or  the  milk  obtainable  is  whole  milk  and  the 
peojDle  are  not  sufficiently  intelligent  to  construct  top-milk  mixtures. 
In  the  table  of  possible  combinations  with  whole  milk  there  is  a  most 
available  formula : 

Two  per  cent,  of  fat;  1.6  per  cent,  of  proteids.  Whole  milk  having  a  strength 
of  4  per  cent,  of  fat. 

7  feedings  are  needed. 
7  ounces  each. 
49  ounces  in  the  whole  mess. 

Percentage  of  fat  needed,  2,  divided  by  4  per  cent,  in  the  whole 
milk  will  result  as  follows : 

2  sy  AQ i  ^^  ounces  of  milk, 

^  ^  (2.5  ounces  of  diluent. 

Problem  8. — Taking  the  same  infant  with  the  same  49-ounce 
mixture  to  construct  the  formula : 

Three  per  cent,  of  fat ;  2.6  per  cent,  of  proteids.     We  would  need : 

.T        .q r  37  ounces  of  milk, 

^  ^  \  12  ounces  of  diluent. 

Diluents. — Very  little  has  been  said  thus  far  as  to  diluents  in 
modifying  cows'  milk.  The  principal  function  of  diluents  is  to 
dilute  or  cut  up  the  casein  of  the  milk,  and  at  the  same  time  dilute 
the  fat  to  such  a  degree  as  to  make  both  these  ingredients  more  digest- 
ible in  the  infant  stomach.  As  diluents  used  in  modifying  cows' 
milk,  a  solution  of  milk-sugar  of  definite  strength,  barley-gruel,  or 
whey  is  used. 

Solution  of  milk-sugar  should  be  5  or  6  per  cent,  strength.  Milk- 
sugar  chemically  pure  is  sold  in  the  shops  as  such,  and  it  is  dissolved 
in  water  which  has  been  filtered  and  boiled  or  in  distilled  water. 

As  to  barley-water,  the  preparation  of  which  is  detailed  in  full 
elsewhere,  it  should  be  remembered  that  the  milk-sugar  is  dissolved 
in  the  barley-water  while  it  is  being  boiled,  as  in  this  way  there  is 
no  residue. 

Reaction. — Lime-water  is  added  to  all  milk  mixtures  in  order 
not  only  to  make  them  more  alkaline,  but  to  aid,  as  has  been  shown, 
in  the  digestion  of  the  casein  by  delaying  coagiilation  of  casein  in  the 
stomach  and  favoring  the  passage  of  the  milk  or  stomach  contents 


150  '  NUTRITION  AND  INFANT  FEEDING. 

into  the  intestine.  The  food  should  contain,  according  to  Meigs  and 
Eotch,  from  one-twentieth  to  one-twenty-fifth  of  its  bulk  of  lime-water. 

Lime-water  is  made  by  adding  about  an  ounce  of  unslacked  lime 
to  half  a  gallon  of  boiled  or  distilled  water,  shaking  well,  and  then 
allowing  it  to  stand  until  the  supernatant  liquid  is  clear.  It  is  then 
ready  for  use. 

Lime-water  is  best  added  to  the  food  just  before  giving  to  the 
infant.  Thus,  to  an  8-ounce  mixture  are  added  3  teaspoonfuls  of 
lime-water.  I  generally  advise  the  omission  of  the  lime-water  after 
the  sixth  month  of  infancy. 

When  is  a  Bottle-fed  Infant  Thriving? — It  may  be  said  that  a 
bottle-fed  infant  is  thriving  if  it  increases  regularly  in  weight,  wakes 
up  betimes  to  nurse  the  bottle,  does  not  suffer  from  colic,  and  has 
movements  of  uniform  consistence  and  color.  It  should  not  "  spit 
up,"  as  it  is  said,  to  an  inordinate  degree.  There  should  be  no  rejec- 
tion of  food  after  the  bottle  has  been  given,  thus  showing  that  the 
quantity  has  been  accurately  gauged.  The  color  of  the  infant  should 
be  good.  The  young  infant  should  sleep  most  of  the  time,  except 
when  nursing  or  engaged  in  play.  Older  infants  should  have  a 
happy,  contented  expression  of  the  face. 

We  do  not  consider  an  infant  with  a  very  large  deposit  of  fat  as 
necessarily  a  healthy  one.  On  the  other  hand,  another  of  exactly  the 
average  weight  may  be  much  healthier  than  the  infant  who  is  over- 
weight. Thus,  the  physician  will  have  to  draw  conclusions  from 
various  data  of  color,  weight,  development,  and  well-being  of  the 
child  as  to  whether  it  is  thriving  on  the  food  mixture. 

Physicians  should  not  be  afraid  to  leave  well  enough  alone  with 
the  artificially  fed  infant,  and,  if  the  gain  during  some  weeks  is  not 
up  to  the  standard,  should  not  be  discouraged,  in  view  of  the  fact 
that  the  succeeding  week  may  show  the  average  gain.  Bottle-fed 
infants  gain  irregularly ;  sometimes  for  a  week  may  appear  to  have 
gained  but  very  little,  an  ounce  or  two.  The  succeeding  week  may 
show  a  marked  recuperation  and  gain  in  weight  above  the  average. 

The  physician  imbued  with  the  principles  of  percentage  feeding 
also  should  not  be  too  hasty  to  change  percentages,  but  should  en- 
deavor to  content  himself  with  a  minimum  number  of  changes.  In 
this  way  the  parents  of  the  infant  will  be  impressed  with  the  fact  that 
the  artificially  fed  infant  is  not  taking,  even  at  the  best,  a  perfect 
food,  but  only  one  which  must  make  up  the  deficiencies  caused  by  the 
lack  of  the  mother's  milk. 

Among  the  disturbances  from  which  apparently  normal  infants 
suffer,  and  by  this  we  refer  to  infants  who  are  thriving,  are,  first, 
constipation.  The  physician  will  see  an  infant  on  one  mixture  have 
two  movements   daily,   perfect   in   color   and   consistence ;    whereas 


ARTIFICIAL  FEEDING  OF  INFANTS. 


151 


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152  NUTRITION  AND  INFANT  FEEDING. 

another  infant  on  the  same  mixtnre  will  be  inordinately  constipated, 
and  movements  hard,  having  the  form  and  consistence  of  scybala. 
He  will  thus  learn  to  account  for  this  constipation  on  various  grounds. 
A  certain  percentage  of  newborn  infants  are  apt  to  be  constipated, 
and  this  constipation  is  due  to  an  inherent  inertia  of  the  g-ut,  and 
also  a  lack  of  secretion  of  the  normal  lubricating  fluids  of  the  gut. 
In  these  cases  also  we  may  find  a  tendency  to  constipation  inherited 
from  the  mother. 

Given  an  infant  with  constipation,  there  are  various  modes  of 
rendering  this  symptom  a  matter  of  less  care  to  the  physician,  as 
well  as  to  those  in  charge  of  the  infant.  If  the  food  is  heated,  it  is 
well  either  to  omit  this  process  or  to  reduce  the  heating  to  a  mini- 
mum. We  should  endeavor  not  to  give  constipated  infants  steril- 
ized food;  but  rather,  in  the  winter  and  fall,  Pasteurized  or  raw 
food.  In  some  cases  it  is  necessary  to  diminish  the  amount  of 
fat  in  the  mixture,  and  in  this  place  we  should  caution  the  physi- 
cian to  go  very  slowly  in  increasing  the  fats.  If  the  fats  are  in- 
creased we  should  never,  especially  with  the  newborn  or  young  infant, 
give  more  than  3  to  4  per  cent,  of  fat.  In  many  cases  4  per  cent, 
of  fat  will  be  followed  by  other  symptoms  fully  as  annoying  as  con- 
stipation. I  refer  to  the  so-called  spitting  or  rejection  of  part  of  the 
food  after  nursing.  This  consists  in  the  bringing  up  of  a  number 
of  curds  in  the  intervals  between  feedings.  These  curds,  as  a  rule, 
have  a  sour  odor  and  are  accompanied  by  eructations  of  gas.  In  such 
cases  it  is  best  to  reduce  the  amount  of  fat,  for  in  very  young  infants 
an  irritation  of  the  stomach  to  any  marked  degree,  as  evidenced  by 
the  rejection  of  a  part  of  the  food  in  the  spitting  of  curds,  may  result 
in  serious  vomiting,  a  symptom  much  more  to  be  feared  than  the  con- 
stipation. However,  in  the  administration  of  top  milk  we  very  often 
find,  especially  with  the  newborn  (and  by  newborn  I  refer  to  infants 
below  three  months  of  age),  that  a  fourth  dilution  of  top  milk  replac- 
ing a  third  dilution  will  often  remedy  the  constipation. 

Spitting. — Spitting,  or  rejection  of  part  of  the  food  after  nursing 
to  any  extent,  may  become  an  annoying  symptom,  and  the  physician 
should  try  his  best  to  remedy  it,  although  the  infant  may  apparently 
be  thriving.  A  breast-fed  infant  may  spit  to  quite  a  degree  and  not 
cause  us  any  uneasiness;  but  it  is  otherwise  with  an  artificially  fed 
infant.  Such  a  condition  may  lead  to  serious  enteric  disturbances, 
necessitating  a  suspension  of  the  food  entirely;  or  the  spitting  may 
be  due  in  some  cases  to  an  excess  of  fat,  and  we  should  try  with  such 
infants,  even  though  thriving,  to  reduce  the  fat  gradually  until  we 
arrive  at  a  point  at  which  the  spitting  is  less  evident,  at  the  same  time 
retaining  the  percentage  of  proteids  in  the  mixture. 

Colic. — Bottle-fed  infants  who  are   apparently   thriving  and   at 


ABTIFICIAL  FEEDING  OF  INFANTS.  1  53 

times  quite  contented  will  have  one  or  two  attacks  of  colic  in  the 
twenty-four  hours.  In  a  breast-fed  infant  we  may  have  a  number 
of  colicky  attacks.  The  breast-fed  child  may  thrive,  the  movements 
may  not  show  much  change  from  the  normal,  and  the  physician  in 
these  cases  is  not  disturbed ;  on  the  other  hand,  in  an  artificially  fed 
infant  an  excessive  degree  of  colic  is  a  cause  of  uneasiness,  not  only 
to  the  family,  but  to  the  physician,  for  it  indicates  that  the  digestion 
of  the  infant  does  not  proceed  along  physiological  lines.  It  has  been 
stated  that  one  or  two  attacks  of  colic  daily  are  not  inconsistent  with 
perfect  health  in  the  infant,  if  the  movements  are  of  normal  con- 
sistence and  color.  On  the  other  hand,  any  excess  of  colic,  combined 
with  a  disturbance  of  the  consistence  and  color  of  the  movements,  the 
appearance  of  curd  particles  or  white  curds  in  the  movements,  or  a 
yellow  movement  containing  too  much  fluid,  mixed  with  white  curds, 
is  a  signal  for  a  change  in  the  percentages  of  fats  of  the  mixture. 
We  should  not,  however,  reduce  them  to  too  low  a  figure.  Less  than 
1  per  cent,  of  fats  for  an  infant  from  three  to  six  months  of  age  will 
result  in  a  diminished  gain  in  the  weight  of  that  infant,  although 
the  infant  may  be  thoroughly  comfortable.  On  the  other  hand,  some 
infants  at  the  age  of  six  to  nine  months  may  digest  2  or  more  per 
cent,  of  fats,  so  that  working  between  these  limits  the  physician  will 
have  to  find  out  the  amount  of  fats  that  can  be  completely  digested 
by  the  infant,  always  bearing  in  mind  never  to  allow  the  proteids  to 
reach  too  low  a  percentage,  else  not  only  diminished  gain  in  weight 
will  result,  but  also  other  disturbances  of  nutrition  which  we  wish 
to  avoid. 

Fat-diarrhcea. — The  physician,  while  increasing  the  proportion  of 
fat  in  his  mixture,  the  infant  thriving  at  the  same  time,  will  find 
that  the  movements  will  at  times  become  fluid,  though  yellow  in  color ; 
and  at  other  times  will  be  more  consistent  and  of  the  same  color. 
With  some  infants  the  movements  will  become  of  an  oily  consistence. 
In  such  extreme  cases  there  will  also  be  uneasiness  with  the  move- 
ments, and  colicky  attacks.  Movements  which  are  normal  in  color, 
contain  no  curds,  whose  consistence  is  of  an  oily  character,  indicate 
that  the  fats  are  in  excess  of  the  necessary  quantity.  Such  infants 
may  even  gain  in  weight  on  this  excessive  amount  of  fat.  The  food 
should  be  suspended  in  these  cases  for  a  few  hours,  and  the  mixture 
administered  with  a  diminished  amount  of  fat.  Such  infants  will 
do  well  on  low  percentages;  whereas  other  infants  of  the  same  age 
will  take  more  fat  and  still  give  no  evidences  of  fat-diarrhoea. 

Greenish  Movements. — Bottle-fed  infants,  apparently  thriving  Vill 
have  at  times  movements  which  contain  green  residue  and  white 
curds,  and  this  will  be  followed  by  a  movement  which  is  perfectly 
normal  in  color  and  consistence.     This  may  be  repeated  at  intervals 


154  NUTRITION  AND  INFANT  FEEDING. 

of  a  week,  and  I  am  accustomed  to  lay  no  stress  on  such,  an  occur- 
rence. On  the  other  hand,  if  such  green  movements  occur  frequently 
and  are  accompanied  hy  colicky  pains,  it  indicates  that  the  milk  is 
not  digested.  Such  infants  can  scarcely  be  included  in  the  normal 
category;  they  are  simply  mentioned  here,  and  the  subject  will  be 
taken  up  in  another  section. 

Disturbances  on  the  Boundary  Line  between  the  Normal  and  the 
Abnormal. — Vomiting. — Some  mothers  will  tell  the  physician  that  the 
child  vomits  a  certain  amount  of  its  food  once  or  twice  daily  and  does 
not  seem  to  be  very  much  disturbed  by  it.  If  such  an  infant  in- 
creases in  weight,  looks  well,  and  has  movements  of  normal  consis- 
tence there  is  very  little  indication  for  our  interference,  except, 
perhaps,  to  reduce  slightly  the  amount  of  food  administered  at  each 
nursing.  The  cases,  however,  which  puzzle  the  physician  are  those 
which  vomit  2  or  3  times  daily,  and  which  do  not  increase  in  weight 
in  a  physiological  ratio.  Such  infants  increase  slightly  in  weight  at 
first,  and  after  a  time  cease  to  increase.  We  have  then  to  deal  with 
an  abnormal  condition. 

Too  Low  a  Percentage  of  Proteids. — It  has  been  mentioned  that 
the  physician  should  be  cautious  not  to  reduce  the  percentage  of 
proteids  beyond  a  certain  limit.  If  he  does,  the  child  will  not  only 
fail  to  increase  in  weight,  but  the  development  of  the  child  will  be 
below  the  normal,  and  we  may  even  incur  the  danger  of  scurvy,  pro- 
nounced rachitis,  and  other  evidences  of  disturbed  nutrition. 

Too  Low  a  Percentage  of  Fats. — Too  low  a  percentage  of  fats  will 
also  result  in  disturbed  nutrition  to  the  infant.  By  this  we  refer  to 
a  percentage  of  1.5  of  fat  for  an  infant  five  months  of  age.  If  such 
a  percentage  of  fat  is  continued  for  two  or  three  months,  the  infant 
will  cease  to  increase  in  weight  and  will  develop  those  disturbances  of 
nutrition  already  mentioned. 

Assimilation  of  the  Food  Without  Increase  in  Weight. — It  is  not  in- 
frequent, especially  in  the  newborn,  to  find  infants  who  completely 
assimilate  the  mixture  we  administer  to  them.  They  sleep  well,  are 
not  disturbed  by  colic,  the  movements  may  be  constipated  or  of  normal 
consistence  and  color,  and  still  the  infant  fails  to  increase  in  weight. 
These  are  the  bafiling  cases.  An  increase  in  the  percentages  for  the 
newborn  infant,  or  in  the  quantity  of  the  mixture,  can  be  made  within 
certain  limits.  If  we  overstep  the  bounds,  the  mixture  will  disagree 
with  the  infant  and  cause  symptoms  which  will  necessitate  a  tem- 
porary suspension  of  the  food. 

When  Shall  the  Food  be  Peptonized? — It  has  been  mentioned 
elsewhere  by  the  author  that  in  peptonizing  the  food  he  makes  use  of 
only  one  method — the  cold  method — for  the  reason  that  most  infants 
will  not  object  to  the  taste  of  the  food  when  this  method  is  employed. 


ARTIFICIAL  FEEDING  OF  INFANTS.  155 

The  cases  in  which  an  attempt  should  be  made  to  peptonize  the  food 
are  as  follows :  The  newborn  infant  is  placed  upon  a  percentage  mix- 
ture. It  suffers  from  constant  colic,  sleeps  very  little,  has  move- 
ments which  are  green,  mixed  with  curds;  on  the  whole  the  infant 
remains  stationary  in  weight  or  the  increase  is  very  slight. 

In  these  cases  most  satisfactory  results  are  sometimes  obtained 
by  peptonizing  the  food  in  the  following  way :  Just  before  the  food  is 
administered  a  third  or  a  quarter  of  a  so-called  peptonizing  tube  is 
added  to  the  milk;  it  is  well  shaken  and  heated  for  two  minutes. 
With  this  exposure  to  warmth  there  is  very  little  development  of  the 
bitter  taste  in  the  milk.  It  is  then  given  to  the  infant.  It  is  sur- 
prising to  see  what  an  immediate  change  occurs  in  the  general  con- 
dition of  the  infant.  The  child  will  sleep,  the  pain  and  colicky  attacks 
disappear,  the  movements  become  yellow  in  color  and  normal  in 
consistence;  the  increase  of  weight  will  begin  and  continue  along 
physiological  lines.  The  physician  must  not  expect,  however,  that 
this  result  will  follow  in  every  case.  It  is  to  be  supposed  that  before 
any  attempt  is  made  at  peptonizing  the  mixture  the  physician  has 
made  every  effort  to  find  the  correct  proportions  for  his  particular 
patient,  and  having  satisfied  himself  that  there  is  a  difiiculty  in  the 
digestion,  he  may  proceed  to  peptonize  the  milk,  but  not  under  any 
any  other  conditions. 

Whey  Method  of  Modification  of  Cows'  Milk.— This  method  is 
really  very  old.  In  Routh's  "  Infant-feeding "  we  have  the  whey 
method,  similar  to  that  which  is  practised  to-day,  described  by  Mr. 
Lobb.  This  gentleman,  in  a  brochure  on  hygiene,  read  before  the 
Harveian  Society,  gave  the  details  of  preparing  a  "  compound  resem- 
bling human  milk,"  and  this  mode  of  modification  of  cows'  milk  as 
devised  by  Professor  Falkland.  Recently  the  method  has  been  taken 
up  by  Vigier,  and  elaborated  by  Monti,  of  Vienna,  in  1897.  Botch 
has  advocated  this  method  of  diluting  milk  for  feeding  infants  with 
difficult  digestion. 

Whey  has  a  composition,  according  to  Konig  of — - 

Proteid 0.8  per  cent. 

Fat 0.2        " 

Sugar  . 4.7        |' 

Lactic  acid      0.3        " 

Salts 0.6        " 

The  proteid  contained  in  whey  includes  the  lactalbumin  of  the  milk 
and  lactoprotein.  The  salts  are  potassium,  sodium,  lime,  and  mag- 
nesium, with  iron  in  combination  with  chlorine,  phosphorus,  and  sul- 
phuric acid. 

Whey  is  made  by  adding  1  part  of  rennet  to  200  parts  of  milk 
at  a  temperature  of  35°  to  40°  C.  (95°  to  104°  F.),  or  a  tablespoon- 


156  '  NUTRITION  AND  INFANT  FEEDING. 

ful  of  the  rennet  sold  in  the  shops  may  be  added,  roughly  speaking, 
to  a  quart  of  milk,  allowed  to  stand,  mixing  thoroughly  until  the 
milk  separates  into  a  liquid  and  a  curd  portion.  The  curd  is  then 
broken  up  thoroughly  and  the  whole  is  strained  through  cheese- 
cloth. About  20  ounces  of  whey  may  be  thus  obtained  from  a 
quart  of  milk.  The  rennin  of  the  rennet  is  still  existent  in  the 
whey,  and  must  be  destroyed  before  the  whey  can  be  mixed  either 
with  milk  or  cream  for  the  purpose  of  modification.  In  order  to 
do  this  the  whey  must  be  heated  to  the  temperature  of  165°  F.,  at 
least — that  is,  Pasteurized — for  thirty  minutes.  Older  authors  advo- 
cated bringing  the  whey  to  a  boil.  Whey,  as  such,  without  the 
addition  of  cream  or  milk,  is  exceedingly  useful  in  feeding  infants 
who  are  suffering  from  enteric  catarrh.  It  contains,  as  is  seen,  the 
liquid  proteid  substances  of  the  milk,  with  salts  and  water.  An 
infant  can  be  kept  on  such  a  diet  for  several  days  without  the 
danger  of  being  starved.  It  has  certain  advantages  over  albumin- 
water,  which  will  be  described  later.  It  is  acid  in  reaction,  and 
may  be  sweetened  with  sugar  if  the  children  object  to  taking  it. 

The  principle  of  its  introduction  into  infant-feeding,  combined 
with  certain  percentages  of  cream,  is  founded  on  the  fact  that,  when 
we  modify  cream  or  milk  to  make  it  conform  to  the  formula  as 
found  in  human  milk,  we  are  still  dealing  with  a  casein  which  is 
not  present  in  proportion  to  the  lactalbumin  as  it  is  in  human  milk. 
By  thus  separating  the  liquid  proteids  from  the  casein  and  recom- 
bining  them  this  disparity  of  percentage  is  overcome. 

The  proportion,  as  has  been  stated  before,  of  the  casein  or  case- 
inogen  to  the  remaining  proteids  of  cows'  milk — the  lactalbumin 
and  lactoglobulin — is  five-sixths  of  casein  to  one-sixth  of  lactalbu- 
min and  lactoglobulin,  as  compared  to  human  milk,  which  contains 
two  sixths  of  caseinogen  and  four-sixths  of  lactalbumin  and  lacto- 
globulin. In  the  whey  we  obtain  all  the  absorbable  proteids;  and 
if  we  use  cream,  which  is  highly  concentrated,  for  fat-proportions 
and  skim  milk  to  obtain  the  caseinogen,  we  can  make  a  mixture 
which  both  relatively  and  actually  contains  the  same  proportions  of 
caseinogen,  lactalbumin,  and  lactoglobulin  as  human  milk.  It  must  be 
said  at  the  start,  however,  that  the  preparation  of  milk  modified 
by  the  whey  method  is  carried  out  with  the  greatest  difficulty  at 
home ;  and  even  when  constructed  at  the  laboratory  the  method  has 
not  yet  been  perfected  to  such  an  extent  as  to  be  entirely  devoid  of 
objection.  It  very  frequently  happens  that  unless  the  whey  is  thor- 
oughly and  most  carefully  Pasteurized,  the  modified  milk  curdles 
when  heated.  It  is  very  difficult  thus  to  prepare  the  whey  mixture. 
It  has  not  come  into  vogue  for  the  reason  that  the  physicians  have  not 
yet  accustomed  themselves  to  the  theory  of  preparing  these  solutions. 


SHALL  THE  PHYSICIAN  BESOBT  TO  INFANT  FOODS ^  157 

It  is  also  found  that  the  manipulation  to  which  the  milk  is  subjected 
is  open  to  the  same  objections  that  ordinarily  obtain  with  modified 
milk  as  prepared  at  the  laboratory.  Children,  for  some  reason  not 
yet  explained,  do  not  thrive  as  well  on  these  carefully  prepared 
mixtures  as  they  do  on  mixtures  prepared  in  the  ordinary  way. 
White  and  Ladd  have  reduced  casein  in  these  mixtures  so  that, 
with  concentrated  cream,  skim  milk,  and  whey,  they  obtain  mixtures 
in  which  caseinogen  and  casein,  as  stated,  bear  the  same  proportions 
relatively  to  the  lactalbumin  and  lactoglobulin  as  it  does  in  the 
human  milk ;  that  is,  with  a  total  proteid  percentage  of  1.25,  two- 
thirds  are  whey  proteids  and  one-third  caseinogen. 

The  following  table  shows  a  few  of  the  combinations  of  caseinogen 
and  lactalbumin  obtainable  from  the  laboratory : 

Fat.  Caseinogen.  Lactalbumin.  Sugar. 

1.00       per  cent.  0.25  per  cent.  0.25  per  cent.  4  to  7  per  cent. 

1.50  "  0.25       "  0.75       "  4  to  7 

2.00  "  0.50       "  0.75       "  4  to  7 

2.50  "  0.50       "  0.75       "  4  to  7 

3.00  or  3.50       "  0.50       "  0.75       "  4  to  7 

SHALL    THE    PHYSICIAN    RESORT    TO    INFANT    FOODS? 

Under  the  heading  of  Infant  Foods  have  been  indicated  the  con- 
ditions under  which  these  foods  may  be  utilized.  iSTo  conditions 
there  laid  down  presuppose  that  any  infant  food  may  be  used  as  an 
exclusive  diet  for  the  infant.  Infant  foods  are  only  either  a  tem- 
porary makeshift — where  milk  for  some  reason  must  be  excluded 
from  the  dietary — or  they  may  be  added  to  milk  to  aid  its  assimila- 
tion. In  the  first  set  belong  the  infant  foods  which  have  been  indi- 
cated under  the  heading  devoted  to  this  subject,  such  as  Imperial 
Granum  or  the  carefully  prepared  cereals.  These  foods  are  used  in 
forms  of  dyspepsia  or  intestinal  disease  to  tide  over  a  critical  period. 
To  the  second  class  belong  the  infant  foods  of  the  malted  varieties, 
such  as  Mellin's  Food,  which  are  added  to  the  milk  to  aid  its  assimi- 
lation. In  other  words,  we  utilize  the  diastase  or  malted  sugar  to 
aid  in  the  digestion  of  the  proteids  of  the  milk. 

Barley-gruels  and  How  to  Utilize  Them. — Some  physicians  ob- 
ject to  the  addition  of  barley-gruel  in  any  strength  to  the  milk 
intended  for  the  normal  infant,  on  the  ground  that  the  gut  of  the 
infant  is  not  prepared  for  the  assimilation  of  starchy  food,  and  we 
find  authorities  who  deprecate  the  use  of  barley-gruel  for  the  new- 
born infant,  on  the  ground  that  it  is  difficult  of  digestion.  We 
find  others  who  deprecate  the  use  of  barley-gruel  under  all  conditions 
other  than  actual  disease.     The  author's  experience  does  not  carrv  out 


158  NUTBITION  AND  INFANT  FEEDING. 

the  assertion  that  harley-gruel  is  not  well  borne  by  the  newborn  infant. 
On  the  contrary,  some  of  the  most  successful  cases  of  infant-feeding 
are  those  of  newborn  infants  whose  percentage  mixture  contained 
as  a  basis  a  thin  barley-gTuel.  These  cases  are  especially  those  new- 
bom  infants  with  whom  the  digestion  of  the  fats  is  very  difficult. 
The  barley-gruel  for  these  infants  is  as  follows:  A  heaping  tea- 
spoonful  of  Eobinson's  Patent  Barley  is  allowed  to  a  pint  of  water. 
This  is  dissolved,  then  stirred  over  a  gas-flame,  brought  to  a  boil,  and 
kept  at  this  temperature  for  fully  ten  minutes.  While  the  barley- 
gruel  is  boiling,  the  amount  of  milk-sugar  requisite  for  the  infant's 
mixture  is  added.  The  gruel  is  then  allowed  to  cool,  and  the  top 
cream  is  added  in  the  requisite  percentage  quantity.  If  prepared  in 
this  way  we  will  have  greater  success  than  with  a  barley-gruel  only 
momentarily  heated  to  the  boiling-point. 

Milk  mixtures  prepared  in  this  way  have  a  consistence  of  thin 
gruel  and  are  quite  well  borne,  not  only  by  the  newborn  infant,  but 
throughout  the  nursing  period.  The  use  of  so-called  dextrinized 
barley  in  the  making  of  the  gruel,  on  the  other  hand,  is  not  well  borne 
by  younger  infants,  inasmuch  as  there  is  a  greater  residue  and  the 
solution  is  not  as  complete  as  with  the  ordinary  Eobinson's  Patent 
Barley. 

Dextrinized  barley  is  rather  indicated  from  the  third  month  to 
the  later  periods  of  infancy,  and  even  when  this  gruel  is  not  as  well 
borne  by  some  infants  as  the  ordinary  barley-gruel  above  indicated. 
There  is  no  question  in  my  mind  that  the  addition  of  a  barley-gruel 
to  a  milk  mixture  aids  in  the  assimilation  of  the  curd  of  the  milk. 
This  can  be  well  seen  when  an  infant  taking  such  a  mixture  spits  up 
a  small  quantity  after  feeding.  The  curd  thus  rejected  is  very  finely 
divided,  and  closely  resembles  the  curd  of  mother's  milk. 

Dextrinized  Gruels  as  Infant  Food. — Jacobi  was  the  first  in  this 
country  to  advocate  the  addition  of  a  cereal  decoction  to  milk  in  di- 
lutions to  aid  the  digestion  of  the  casein  in  the  cows'  milk.  From  this 
has  developed  the  addition  of  dextrinized  gruels  to  cows'  milk,  with 
the  same  end  in  view.  Chapin,  in  this  country,  and  Keller,  in 
Germany,  advocate  this  method  of  infant-feeding. 

So  far  as  the  Chapin  method  is  concerned,  it  consists  principally 
in  dextrinizing  a  thin  gruel  of  barley  or  flour  by  means  of  a  diastase 
preparation  (Cereo),  adding  this  to  the  milk,  and  administering  it  in 
this  fashion  to  the  infant.  Chapin  advocates  the  administration  of 
dextrinized  gruels  in  combination  with  milk  in  percentage  dilutions 
both  for  healthy  and  sick  infants.  The  author  cannot  see  the  necessity 
for  dextrinizing  any  dilution  of  milk  for  the  normal  infant. 

Keller  has  advocated  the  use  of  these  gruels  with  sick  infants. 


SHALL  THE  PHYSICIAN  BESORT  TO  INFANT  FOODS?  159 

especially  of  the  marantic  type,  and  in  this  respect  the  author's 
experience  carries  out  the  contention  of  Keller,  that  much  can  be 
accomplished  by  the  use  of  these  dextrinized  gruels.  The  majority 
of  pediatrists  use  no  other  diluent  than  water  for  the  milk  of  normal 
infants.  In  the  present  method  some  form  of  diastase,  either  pure  or 
combined  with  malt  extract,  is  added  to  the  cereal  dilution.  Chapin 
takes  a  tablespoonful  of  flour,  adds  this  to  1^  pints  of  water,  and  boils 
the  mixture  for  fifteen  minutes.  He  then  adds  a  teaspoonful  of  a 
solution  of  diastase  (so-called  Cereo)  to  the  mixture,  the  gruel  be- 
comes thin,  and  is  then  considered  dextrinized.  In  this  form  it  is 
added  to  the  milk  as  a  diluent  in  the  requisite  quantity. 

Keller  utilizes  the  formula  of  Liebig  in  making  a  malt  extract. 
To  this  malt  extract  potassium  carbonate  is  added  as  an  animal  salt. 
One  hundred  grammes  of  this  malt  extract  are  added  to  500  c.c.  of 
water,  or  1  pint,  and  dissolved.  This  is  solution  l^o.  1.  He  then 
suspends  50  grammes  of  wheat  flour  in  500  c.c.  of  milk,  so  that  the 
solution  is  quite  uniform.  He  then  strains  the  milk  and  flour  through 
cheesecloth.  The  solution  of  malt  extract  and  that  of  the  milk  and 
flour  are  mixed  together,  put  into  a  common  vessel,  and  stirred  con- 
stantly over  a  slow  fire.  After  about  twenty  minutes  of  stirring  the 
whole  mixture  is  brought  to  a  boil  to  stop  all  processes  of  digestion. 
The  mixture  is  now  put  up  in  bottles,  each  containing  about  6  ounces, 
corked,  and  kept  cool.  This  mixture  contains  dextrinized  cereal  and 
malt-sugar  in  addition  to  the  milk.  The  Liebig  malt  extract  utilized 
by  Keller  is  composed  of  maltose,  57  per  cent. ;  dextrine,  12,4  per 
cent.  Wheat  contains  66.8  per  cent,  of  starch,  7.5  per  cent,  of 
dextrine,  and  a  small  amount  of  dextrose.  By  the  action  of  the 
ferments  in  the  malt  extracts — principally  diastase — the  starches  are 
converted  into  sugars.  By  this  method  a  number  of  easily  assim- 
ilable substances  are  introduced  into  the  economy.  The  action  of 
these  processes  on  the  casein  coagulation  seems  favorable  to  its 
assimilation. 

The  acid  intoxication  of  intestinal  origin  said  to  be  present  in 
these  infants,  is  neutralized.  Ammonia,  which  is  an  index  of  dis- 
turbed intestinal  metabolism,  diminishes  and  finally  disappears  from 
the  urine.  It  should  be  borne  in  mind,  however,  that  in  feeding  in- 
fants of  the  marantic  type  on  dextrinized  gruel  or  any  over-cooked 
food,  there  is  great  danger  of  the  development  of  scurvy.  We  cannot 
therefore  feed  these  infants  for  any  length  of  time  on  these  foods, 
for  not  only  do  they  develop  scorbutic  symptoms,  but  after  a  while 
cease  to  increase  in  weight,  or  remain  stationary,  become  anemic,  and 
are  then  in  as  bad  a  condition  as  they  were  at  first. 


160  '  NUTRITION  AND  INFANT  FEEDING. 

FOOD    OF   BREAST-FED    OR  BOTTLE-FED   INFANTS   AFTER   THE 

SIXTH    MONTH. 

It  has  been  shown  by  Camerer  and  Rotch  that  the  secretion  of 
breast  milk  reaches  its  highest  limits,  both  in  quality  and  quantity, 
during  the  first  six  months  of  lactation.  In  many  cases  the  quantity 
of  milk  diminishes,  as  also  its  quality.  If  the  infant  gains  steadily  in 
weight  after  the  sixth  month,  no  additional  food  is  indicated.  If, 
however,  the  increase  of  weight  is  not  satisfactory,  we  may  at  this 
period  begin  with  the  daily  administration  of  one  or  two  bottles  of 
modified  cows'  milk,  in  addition  to  the  breast,  continued  until  the 
infant  is  completely  weaned.  On  the  eruption  of  the  incisor  teeth,  at 
the  seventh  month,  the  infant  is  allowed  a  cereal,  in  the  shape  of  pre- 
pared barley,  as  a  pap,  with  cracker  or  rusk  of  bread  once  or  twice 
a  day.  If  the  infant  is  inclined  to  be  constipated,  the  barley  is 
omitted.  The  same  procedure  is  followed  as  to  cereals  with  bottle- 
fed  infants  after  the  seventh  or  eighth  month. 

FEEDING    FROM    THE    NINTH    TO    THE    TWELFTH    MONTH. 

Breast-fed  Infants. — Weaning. — It  is  not  advisable  to  attempt 
weaning  at  the  outset  of  the  summer,  even  though  we  may  be  com- 
pelled to  keep  the  infant  at  the  breast  a  few  months  longer  than 
usual.  If  the  infant  is  ^^artially  weaned — that  is,  on  a  mixed  feed- 
ing of  breast  and  bottle — it  should  not  be  deprived  of  the  breast 
entirely  during  the  summer  season.  The  reason  for  this  is  quite 
evident.  During  the  summer  a  bottle-fed  infant  is  very  likely  to  be 
upset  should  anything  happen  to  the  milk.  We  would  therefore  be 
compelled  to  suspend  the  feeding  with  the  bottle,  proceed  without 
milk  for  a  few  days,  and  then  gradually  return  to  the  milk  diet. 
In  doing  this  our  task  will  be  less  difficult  if  we  have  even  a  scantily 
secreted  breast  milk  at  our  disposal.  Convalescence  from  a  dys- 
]Deptic  attack  will  be  much  more  rapid  if  return  is  made  cautiously 
to  breast  milk  than  to  a  substitute  feeding. 

It  takes  about  eight  weeks  to  wean  an  infant  completely.  Sudden 
weaning  of  an  infant  from  the  breast  is  not  only  inadvisable,  but  in 
some  cases  attended  with  the  greatest  difficulties.  If  the  infant  has 
had  the  benefit  of  one  or  two  additional  bottles  daily  from  the  sixth 
month,  the  task  of  weaning  is  comparatively  simple.  If,  however, 
the  infant  has  been  kept  on  the  breast  exclusively  until  the  ninth 
month,  when  weaning  is  attempted  certain  difficulties  will  at  once 
appear.  The  infant  will  not  take  the  bottle  if  there  is  a  breast  at 
its  disposal.  The  only  way  out  of  the  difficulty  is  to  deprive  the 
infant  at  certain  times  of  the  day  of  the  breast,  and  thus  starve  it 
into  taking  the  bottle.  This  requires  moral  courage  on  the  part  of 
the  mother  an<l  of  the  ])liysir'ian. 


FEEDING  FBOM   TWELFTH  TO  EIGHTEENTH  MONTH.  161 

In  those  cases  in  which  the  mother  nurses  the  infant  we  cannot 
always  gain  her  coojDeration  in  denying  the  breast  to  the  infant.  The 
difficulties  of  weaning  in  such  cases  are  only  increased,  but  with 
patience  we  can  ultimately  overcome  them.  I  have  seen  infants  who 
were  deprived  of  the  breast  at  this  period  refuse  to  take  but  a  few 
ounces  of  nourishment  daily  for  weeks.  They  emaciate,  become 
restless,  and  refuse  to  be  pacified.  Under  certain  conditions,  where 
the  nursing  function  has  been  discontinued  and  the  milk  secretion 
has  therefore  ceased,  the  situation  is  at  times  really  critical.  But  I 
have  invariably  seen  the  child  take  to  his  artificial  food  in  due  season, 
even  if  this  surrender  was  delayed  for  a  long  period  of  time.  Patience 
will  ultimately,  conquer  the  little  one  in  these  cases. 

In  weaning  I  give  those  modifications  of  cows'  milk  which  con- 
tain from  1  to  1.5  per  cent,  of  proteids  and  2  to  2.5  per  cent,  of  fats 
until  the  infant  is  fully  weaned.  I  then  increase  the  strength  of  the 
milk  to  that  given  to  the  bottle-fed  infant  at  the  ninth  month.  At 
this  time  the  bottle-fed  infant  is  given  almost  whole  milk.  It  is 
always  well  to  mix  wth  the  milk  a  small  quantity  of  water,  in  the 
proportion  of  1  ounce  of  water  to  7  of  milk.  Some  infants  who 
have  been  at  the  breast  up  to  the  ninth  month  will  apparently  refuse 
to  take  any  modifications  of  milk  which  contain  the  cereal  decoc- 
tions. In  these  cases  I  have  tempted  the  infants  with  small  quanti- 
ties of  raw  milk  slightly  diluted  with  water,  foregoing  all  attempts 
at  percentage  modification.  This  seems  to  have  succeeded  the  best 
in  trying  cases. 

In  addition,  the  author  gives  from  the  ninth  to  the  twelfth  month, 
both  to  breast-  and  bottle-fed  infants,  cereals,  in  the  shape  of  pap 
made  up  with  barley,  granum,  rusk,  and  crackers,  twice  daily.  For 
some  of  these  infants  an  ounce  of  expressed  beef -juice  is  mixed  with 
equal  portions  of  barley-water  and  slightly  salted.  This  is  given 
once  a  day.     Infants  relish  this  change. 

FEEDING  FROM  THE  TWELFTH  TO  THE   EIGHTEENTH  MONTH. 

At  this  period  it  is  desirable  to  place  the  child  on  a  diet  containing 
milk,  cereals,  eggs,  and  beef -juice,  in  the  following  manner:  Four  to 
five  meals  are  given  daily.  At  each,  milk  forms  the  basis  of  nourish- 
ment, generally  accompanied  by  rusk  or  crackers.  An  egg  is  given 
once  a  day,  beginning  with  the  half  and  increasing  to  the  whole  egg  as 
the  infant  grows  older.  At  this  time,  also,  fruit- juices,  such  as 
orange-juice  or  prune-juice,  may  be  given,  especially  to  those  who 
exhibit  a  rachitic  tendency  or  who  are  constipated.  The  juice  of  half 
an  orange  daily  will  be  relished  by  most  children. 

The  dietary  is  divided  into  four  or  five  meals  daily.     If  infants 

11 


162  NUTRITION  AND  INFANT  FEEDING. 

are  markedlj  rachitic  the  author  allows,  in  addition  to  the  dietary 
below,  a  small  amount  of  chicken  meat,  as  much  as  will  adhere  to  the 
bone  of  a  chicken.     This  is  given  to  the  child  once  a  day. 

MilJc. — A  quart  and  a  half  a  pint  to  a  pint  daily. 

Cereals. — Eusk  or  crackers,  two  of  each  a  day;  sponge  cake  in 
the  form  of  long  sugared  slices ;  barley,  granum,  or  oatmeal  (th'3 
latter  strained)  in  the  form  of  a  pap  once  a  day. 

Eggs. — One  soft-boiled  or  coddled  egg  a  day. 

Meat. — Beef-juice  expressed,  mixed  with  equal  portions  of  barley- 
water  and  slightly  salted  to  the  taste,  about  2  to  4  ounces  daily. 

FEEDING  FROM  THE  EIGHTEENTH  MONTH  TO  THE  END  OF  THE 

SECOND  YEAR. 

At  this  time  the  child  is  placed  on  a  mixed  carbohydrate  and 
nitrogenous  diet,  consisting  for  the  most  part  of  milk,  which  is  the 
basis  of  the  diet;  eggs;  soup  or  beef -juice;  meat  of  the  beef  or 
chicken ;  vegetables ;  cereals.     These  are  divided  into  four  meals  daily  : 

Milk. — Some  children  will  take  considerable,  some  very  little, 
milk  at  this  period. 

Eggs. — The  eggs  are  boiled  soft  or  coddled.  Some  children  will 
take  at  least  one  egg  a  day,  others  two ;  some  will  not  take  egg  at  all. 

Soujjs. — Parents  are  apt  to  overstep  the  mark  in  giving  large 
quantities  of  soup — ^in  fact,  an  adult  portion — to  children.  This  is 
scarcely  desirable,  inasmuch  as  it  displaces  other  food,  such  as  milk, 
and  contains  large  quantities  of  salts  and  insoluble  products,  such 
as  keratin.     The  amount  should  not  exceed  4  ounces. 

Meats. — The  ordinary  boiled  meat  is  by  far  the  best  for  children. 
The  inside  of  a  lamb  chop,  a  small  piece  of  well-done  beefsteak, 
roast  beef,  and  chicken.  Gamey  meats,  and  fat  meat,  such  as  mutton, 
ham,  pork,  should  be  avoided. 

Vegetahles. — These  include  potatoes,  peas,  beans,  carrots,  spinach, 
the  green  vegetables  being  especially  desirable,  inasmuch  as  they 
contain  iron.    All  vegetables  should  be  given  in  a  mashed  form. 

Cereals. — These  should  include  barley,  rice,  granum,  wheatena, 
oatmeal,  rusk,  crackers  of  all  kinds,  cocoa,  and  farina. 

Fruits. — Orange-juice,  ripe  apples,  and  pears,  prunes  or  prune- 
juice. 

The  articles  of  diet  which  should  be  avoided  are  vinegar,  cabbage, 
salad,  coffee,  tea,  wine,  soups  that  contain  too  great  an  amount  of 
amylacea. 

A  dietary  consisting  of  the  above  foods  might  be  formulated  as 
follows : 

Up  to  the  end  of  the  third  year : 


FEEDING  F€^  Wm  SIXTH  YEAR  AND  AFTEB.  163 

Breakfast,  8  a.  m.  :  juice  of  one  oraiBg^;,  10  ounces  of  milk,  with  or 
without  a  cereal.    A  slice  of  bread  or  crackers  and  an  egg. 

Dinner,  1  p.  m.  :  120  grammes  (4  ounces)  of  soup ;  75  grammes 
(2.5  ounces)  of  meat  with  vegetables,  and  a  fruit  dessert;  some  milk. 

Afternoon  Lunch,  4  p.  m.  :  250  c.c.  (8  ounces)  of  milk  or  cocoa 
with  rusk  or  crackers. 

Supper,  6:  30  to  7  p.  m.  :  Soft  egg,  250  c.c.  (8  ounces)  of  milk; 
cracker,  toasted  bread,  or  farina  in  the  milk. 

Candy. — I  allow  one  or  two  pieces  of  candy  daily,  generally  good 
chocolate,  to  older  children. 

FEEDING  THE  THIRD  TO  THE  SIXTH  YEAR  AND  AFTER. 

From  the  third  to  the  sixth  year  of  life  the  diet  should  be  mostly 
fluid  or  semifluid.  The  basis  of  all  such  diets  should  be  milk. 
Milk  soups,  eggs,  meat,  butter,  cocoa,  bread,  fresh  vegetables,  and 
fruits.    The  number  of  meals  a  day  should  be  three  or  four. 

The  following  is  a  schedule  of  a  liberal  diet  at  this  time : 

Breakfast,  8  a.  m.  :  orange-juice,  330  c.c.  (11  ounces)  of  milk, 
with  or  without  cereal,  egg,  buttered  bread,  or  toast,  about  half  an 
ounce  of  sweet  butter  being  allowed. 

Dinner,  1  p.  m.  :  180  c.c.  (6  ounces)  of  soup;  meat,  90  grammes 
(3  ounces),  vegetables,  a  dessert,  generally  of  baked  apples. 

Afternoon  Lunch,  4  p.  m.  :  240  c.c.  (8  ounces)  of  milk,  rusk  or 
a  slice  of  bread,  or  cracker. 

Supper,  7  p.  M. :  240  c.c.  (8  ounces)  of  milk  mixed  with  some 
cereal,  generally  farina,  1  soft  egg. 

This  is  a  liberal  diet.  Some  children  will  take  as  much  as  is  here 
prescribed,  others  will  take  less.  Some  children  are  particularly 
fond  of  fish,  and  this  may  be  given  once  or  twice  a  week,  generally 
in  the  boiled  form  with  an  egg  sauce.  Fried  fish  should  not  be 
allowed.  It  is  advisable,  esiDecially  in  exceedingly  nervous  children 
or  in  those  who  have  a  lithic  tendency,  to  substitute  meat  once  or 
twice  weekly  by  fish. 

The  above  form  of  diet  with  slight  modifications  is  suitable  up  to 
the  tenth  year  of  life.  The  object  of  all  dietaries  after  the  eighteenth 
month  is  to  mix  the  carbohydrates,  fat,  and  albuminoids  in  rational 
proportions.  The  following  table  by  Camerer  distinctly  demonstrates 
this : 

(Second  to  Five  to  Seven  to 

fourth  vear.  six  years.  ten  years. 

12.7  kilos.  18.7  kilos.  24  kilos. 

Total  food  (daily)  .    .     1183  grammes.  1517  grammes.  1699  grammes. 

Albumin 46         "  64         "  67         " 

Fat 39        "  46        "  32        " 

Carbohydrates     ...       117        "  197         "  251         " 

Water 957         "  1200         "  1333         " 


1  64      .  NUTHITIOK  AND  INFANT  FEEDING. 

THE    FEEDING    OF    SICK   INFANTS    AND    CHILDREN. 

The  feeding  of  sick  infants  is  considered  under  the  headings  of 
the  various  diseases.  It  must  be  borne  in  mind  that  infants  and 
children,  if  left  to  their  own  resources,  would  take  either  very  little 
nourishment  or  too  much.  In  certain  marantic  conditions  infants  will 
take  very  large  quantities  of  food  if  it  is  given  to  them.  The  infant's 
cries  are  interpreted  by  the  mother  as  being  due  to  hunger,  when 
they  may  be  due  to  colic  or  intestinal  distention.  In  these,  cases  the 
mother  gives  too  great  a  quantity  of  food,  and  the  infants  suffer  from 
distention  of  the  stomach  or  intestine.  In  typhoid  fever,  pneumonia, 
or  other  acute  disease  the  patient,  if  fed  at  long  intervals,  takes  but 
little  food.  Such  patients  should  take  small  quantities  at  short 
intervals.  If  the  infant  takes  a  small  quantity  at  each  feeding,  the 
aggregate  amount  in  twenty-four  hours  is  sufficient  to  maintain 
nutrition. 

After  operations,  such  as  those  for  empyema,  infants  and  children 
must  be  carefully  and  systematically .  fed  in  order  that  they  may 
combat  the  ravages  of  disease.  The  necessity  of  careful  feeding  is 
seen  in  typhoid  fever  in  the  fifth  and  sixth  weeks,  at  which  time 
there  is  great  emaciation  and  the  temperature  has  dropped  to  the 
normal.  If  we  fail  to  feed  these  patients,  they  remain  emaciated 
and  show  slight  inanition  temperatures.  On  the  other  hand,  we  must 
not  give  large  quantities  of  indigestible  food.  AVe  must  choose  the 
foods  carefully.  Convalescents  can  take  much  larger  quantities  of 
food  in  twenty-four  hours  than  the  normal,  healthy  child.  The 
quantity  given  at  each  feeding  should  be  smaller  than  in  health. 
The  nitrogenous  foods,  such  as  milk  and  eggs,  and  also  sugars, 
starches,  and  cereals  of  all  kinds,  are  easily  assimilable.  Alcoholics, 
when  given,  should  be  well  diluted.  Rectal  feeding  is  contraindicated 
in  diarrhoeal  conditions  and  states  of  rectal  intolerance.  On  the 
other  hand,  if  the  stomach  rejects  food  repeatedly,  it  is  well  to  give 
that  organ  complete  rest.  Under  such  conditions  even  water  is  not 
introduced  into  the  stomach.  The  patient  is  fed  for  twenty-four 
hours  or  more  by  rectum. 


SECTION  III. 

DISEASES  OF  THE  NEWBORN. 

PHYSIOLOGY    OF    THE    NEWBORN. 

Respiration. — Inasmuch  as  cardiac  action  and  muscular  move- 
ment occur  during  the  intra-uterine  life  of  the  foetus,  the  first  im- 
portant function  performed  by  the  newborn  infant  is  that  of  respira- 
tion. The  cause  of  the  first  inspiratory  act  of  the  newborn  has  been  a 
matter  of  much  discussion ;  whereas  some  contend  that  mechanical 
stimulus  brought  into  play  by  the  act  of  parturition  is  the  primary 
cause  of  the  first  inspiratory  act  of  the  infant,  others  have  insisted 
that  the  change  of  temperature  from  the  uterus  to  that  of  the  ex- 
ternal world,  acting  on  the  surface  of  the  body,  is  sufficient  stimu- 
lus to  cause,  by  reflex  action,  the  first  act  of  inspiration.  Both 
these  theories  have  been  disproved,  especially  by  the  work  of  Ahl- 
feld.  The  consensus  of  opinion  is,  that  the  first  inspiration  of 
the  newborn  is  a  direct  result  of  the  separation  of  the  placenta 
with  the  cessation  of  the  normal  foetal  aeration  of  the  blood ;  as  a 
result  of  this  there  are  diminution  of  oxygen  in  the  foetal  blood, 
increase  in  carbonic-acid  gas,  and  marked  stimulation  of  the  res- 
piratory centre  of  the  newborn  in  the  medulla.  This  theory  is  borne 
out  by  the  fact  that  in  premature  separation  of  the  placenta  this 
stimulus  to  the  performance  of  inspiration  on  the  part  of  the  foetus 
occurs  before  birth  in  the  uterus  or  in  any  part  of  the  parturient 
canal.  There  are  rare  cases  also  in  which  the  foetus  is  born  before 
separation  of  the  placenta  from  the  walls  of  the  uterus.  In  such 
instances  the  birth  has  been  very  rapid  and  the  resistance  to  the 
passage  of  the  foetus  slight ;  as  a  result  of  the  uterus  having  con- 
tracted but  little,  the  placenta  remains  in  situ  for  a  short  space  of 
time  after  birth  of  the  foetus.  Such  a  case  has  been  published  by 
Kehrer,  and  in  this  case  the  foetus  was  born  in  a  state  of  uterine 
apnoea,  the  color  of  the  skin  being  pink,  the  infant  not  breathing, 
but  at  most  performing  the  intra-uterine  respiratory  movements  of  the 
trunk,  as  described  by  Ahlfeld,  Such  cases  would  seem  to  prove  the 
truth  of  the  theory  that  if  the  placenta  still  remains  attached  to 
the  uterine  walls,  and  the  interchange  of  oxygen  between  the  maternal 
and  foetal  blood  continues,  the  stimulus  to  the  medullary  centres 
mentioned  above  is  lacking.  There  is  thus  no  inspiration  in  such 
cases  until  the  placenta  separates.     Ahlfeld  has  shown  that  in  utero 

165 


166    '  DISEASES  OF  THE  NEWBORN. 

the  foetus  performs  certain  rhythmic  movements  of  the  trunk  and 
extremities,  which  he  interprets  as  respiratory  in  their  nature. 
There  are  thus,  according  to  these  experiments,  respiratory  move- 
ments performed  by  the  foetus  in  utero.  These,  however,  are  of  the 
most  superficial  character,  and  do  not  lead  to  aspiration  of  liquor 
amnii  either  by  mouth  or  nostrils.  It  is  the  intensification  of  these 
intra-uterine  respiratory  movements  which  eventuates  in  the  first  act 
of  respiration  of  the  newborn.  Though  the  existence  of  intra-uterine 
foetal  respiratory  waves  as  conducted  by  the  liquor  amnii  to  the 
uterine  wall  have  been  verified  by  a  number  of  observers,  their  in- 
terpretation is  diverse  and  their  significance  is  still  a  matter  of  dis- 
cussion. 

The  Rhythm, — The  rhythm  of  respiration  in  the  newborn  is  quite 
irregular.  Deep  inspiration  and  expiration  are  followed  by  regular 
respiration,  with  an  apparent  pause  in  which  the  respiratory  move- 
ments are  so  superficial  that  the  infant  scarcely  seems  to  breathe,  and 
in  which  the  respiratory  movements  can  only  be  detected  by  the 
chymograph,  this  in  a  manner  recalling  the  intra-uterine  respiration 
of  Ahlfeld.  During  sleep  the  respiration  is  more  regular,  but  is 
influenced  by  the  least  external  source  of  disturbance,  such  as  a 
change  in  the  surrounding  light,  air,  and  covering  of  the  newborn. 

The  frequency  of  respiration  can  thus  be  of  varying  rapidity. 
Dohrn  found  that,  regardless  of  sleep  or  waking,  the  number  of  res- 
pirations of  the  newborn  was  on  the  average  62 ;  during  the  act  of 
crying  47. 

The  type  of  respiration  in  the  newborn,  either  in  the  male  or 
female,  is  predominantly  thoracic. 

The  Aeration. — The  aeration  of  the  lungs — that  is,  the  replace- 
ment of  inspired  by  expired  air — is  much  more  thorough  in  the  lungs 
of  the  newborn  than  later  in  life.  In  other  words,  if,  as  has  been 
proved  by  Dohrn,  38  c.c.  of  air  are  inspired  on  the  first  day  of  life, 
this  is  renewed  by  each  inspiration  and  expiration  to  such  an  extent 
that  there  is  little  residual  air  in  the  lung.  In  the  adult  lung  the 
contrary  obtains,  there  being,  even  on  forced  expiration,  enough  air 
left  in  the  lung  and  retained  there  to  be  demonstrated  by  collapse  of 
the  organ  when  the  thorax  is  opened  and  atmospheric  pressure  is 
allowed  to  act  on  the  viscus.  In  the  newborn,  if  the  thorax  is  opened 
post-mortem,  no  such  collapse  of  the  lung  takes  place,  but  enough  air 
remains  in  the  organ  to  enable  it  to  float  if  placed  in  water — that  is, 
a  minimum  amount  of  air.  The  lung  of  the  newborn  unfolds  gradu- 
ally, so  that  in  an  infant  two  weeks  old  there  are  patches  of  the 
lung  which  have  still  not  been  aerated,  although  the  infant  has 
breathed  normally  all  this  time.  That  the  lung  does  unfold  gradu- 
ally is  proved  by  the  fact  that,  while  immediately  postpartum,  38  c.c. 


PHYSIOLOGY  OF  THE  NEWBOEN.  167 

of  air  are  taken  into  the  lungs  with  each  inspiration,  this,  on  the 
tenth  day  of  life,  has  increased  to  a  volume  of  50  c.c. 

Circulation. — At  the  moment  of  birth  of  the  infant  certain  changes 
take  place  in  the  circulatory  system  which  mark  the  transition  from 
intra-uterine  as  distinguished  from  extra-uterine  life.  These  changes 
occur  in  the  foramen  ovale,  the  ductus  Botalli,  and  the  umbilical  ar- 
teries and  veins.  On  the  first  inspiration  the  lungs  expand  and  the 
blood  passes  into  the  organ.  The  pressure  is  immediately  lowered  in 
the  right  auricle  on  account  of  the  diminished  resistance  of  the  pulmo- 
nary capillaries;  the  pressure  in  the  left  auricle  is  correspondingly 
increased.  The  foramen  ovale,  situated  in  the  auricular  septum, 
with  a  valvular  slit-like  opening  toward  the  left  auricle,  is  naturally 
closed  by  the  increased  pressure  in  the  left  auricle,  and  from  thence 
forward  there  is  no  interchange  of  blood  between  the  right  and  left 
auricle  as  in  foetal  life. 

The  closure  of  the  ductus  Botalli  is  a  matter  of  much  discussion. 
The  explanation  of  its  closure  given  by  Strassmann  is  now  accepted 
by  most  observers.  On  expansion  of  the  lungs  and  the  establish- 
ment of  the  smaller  pulmonary  circulation,  the  pressure  in  the  pul- 
monary artery  is  diminished  and  that  in  the  aorta  increased.  The 
ductus  Botalli,  passing  as  it  does  from  before  backward  from  the 
pulmonary  artery  to  the  aorta,  enters  the  latter  vessel  at  an  acute 
angle.  Its  lumen  at  the  aortic  extremity  is  funnel-like  and  closed 
by  a  slit-like  valvular  arrangement,  whereas  during  foetal  life,  the 
pressure  being  greater  in  the  pulmonary  artery  than  in  the  aorta,  it 
was  possible  for  blood  to  pass  through  the  ductus  Botalli  into  the 
aorta.  At  birth,  the  pressure  conditions  being  reversed,  it  becomes 
impossible  for  blood  to  pass  from  the  pulmonary  artery  to  the  aorta, 
the  pressure  in  the  pulmonary  artery  not  being  equal  to  driving  the 
blood  through  the  ductus  against  the  increased  postnatal  pressure 
in  the  aorta.  The  ductus  thus  becomes  emptied,  and  its  function  as 
a  circulatory  organ  connecting  the  pulmonary  artery  and  the  aorta 
ceases.  'No  clot  is  formed  except  in  rare  cases  in  the  lumen  of  the 
ductus.  In  utero,  from  the  fifth  month  on,  there  is  a  gradual  dimi- 
nution in  the  calibre  of  the  vessel ;  within  two  or  three  days  after 
birth  the  calibre  is  so  narrowed  that  a  probe  cannot  be  insinuated 
within  it.  The  aortic  extremity  in  many  cases  is  never  entirely  oc- 
cluded, although  most  of  the  vessels  became  subsequently  obliterated. 

At  birth  the  umbilical  arteries  are  closed  by  a  process  similar  to 
that  which  is  described  above.  The  first  inspiration  with  conse- 
quent inflation  of  the  lung  and  the  establishment  of  the  pulmonary 
circulation  causes  a  fall  of  arterial  pressure  in  the  descending  aorta. 
The  blood  ceases  to  flow  through  the  umbilical  arteries.  The  mus- 
cular coats  of  these  vessels,  being  particularly  well  developed,  tend 


168  DISEASES  OF  THE  NEWBOBN. 

to  contract,  and  enclose  in  their  lumen  an  extended  fibrinous  clot. 
When  the  cord  is  tied  this  clot  extends  from  the  umbilicus  to  the 
hypogastric  arteries.  It  is  the  adherence  of  the  thrombi  to  the  walls 
of  these  vessels  and  their  subsequent  organization  which  causes  the 
obliteration  of  the  lumen  of  the  umbilical  arteries,  although  this  is 
not  complete  except  at  the  situation  of  the  umbilicus. 

The  umbilical  veins  are  obliterated  in  a  physiological  manner  by 
the  pressure  of  the  uterus  on  the  placenta.  This  forces  the  reserve 
blood  in  the  placenta  into  the  body  of  the  foetus,  the  act  of  inspiration 
favoring  the  flow  of  blood  from  the  placenta  to  the  body  of  the  foetus. 
Budin  has  shov^n  that  if  the  umbilical  cord  is  divided  too  soon  after 
birth  blood  to  the  amount  of  about  100  c.c.  flows  from  the  veins.  If 
ligation  of  the  cord  is  delayed,  however,  this  quantity  of  blood  is 
aspirated,  so  to  speak,  by  the  infant  into  its  body  from  the  placental 
sinuses. 

After  ligation  of  the  cord,  therefore,  the  natural  physiological 
condition  of  the  circulation  favors  the  collapse  and  obliteration  of  the 
umbilical  veins. 

Pulse. — The  pulse  of  the  newborn  infant  is  irregular  in  frequency 
and  shows  certain  constant  characteristics.  Immediately  after  birth 
the  frequency  reaches  150  to  190  beats  a  minute.  This  rapidity  is 
due  probably  to  the  new  conditions  inaugurated  at  birth  in  the  cir- 
culation and  the  increased  amount  of  work  caused  by  respiration  and 
pulmonary  circulation,  thrown  upon  the  left  ventricle.  After  a  short 
lapse  of  time,  from  twenty  minutes  to  an  hour  after  birth,  the  pulse 
frequency  sinks  to  less  than  100  during  sleep.  During  waking, 
nursing,  crying,  muscular  exercise,  there  is  a  slight  increase  in  fre- 
quency. After  three  to  flve  days  the  pulse  mounts  in  frequency  from 
120  to  135  beats  per  minute,  but  never  again  attains  the  rapidity 
observed  immediately  after  birth.  The  rise  in  frequency  of  the 
pulse  after  its  primary  fall  may  be  due  not  only  to  the  recovery  of 
the  circulatory  system,  especially  the  heart,  from  the  effects  of  rapid 
changes  of  tension  in  its  various  parts,  incident  to  the  new  extra- 
uterine conditions,  but  to  the  beginning  influence  of  the  vagus  on 
the  left  ventricle. 

The  influence  of  sex  on  the  frequency  of  the  pulse  is  evident  in 
the  newborn  as  in  later  life,  the  pulse  of  girls  during  sleep  being 
two  or  three  beats  more  frequent  to  the  minute  than  that  of  boys. 
During  exercise  the  pulse  of  the  male  newborn  infant  is  more  fre- 
quent than  that  of  the  female.  The  true  cause  of  these  differences 
is  as  yet  obscure. 

Blood. — The  amount  of  blood  of  the  newborn  as  compared  with 
the  body-weight  varies  with  the  time  of  ligation  of  the  umbilical  cord. 
If  the  cord  is  ligated  at  once  the  quantity  of  blood  is  one-fourteenth 


PHYSIOLOGY  OF  THE  NEWBOEN.  -      169 

to  one-sixteenth,  of  that  of  the  body-weight;  whereas  in  cases  of  late 
ligation  of  the  cord  it  is  one-tenth  to  one-eleventh  of  the  body-weight. 

The  histological  characteristics  of  the  blood  of  the  newborn  are 
so  striking  as  to  merit  brief  mention  here.  The  blood  contains  a 
large  number  of  nucleated  red  blood-cells ;  the  red  blood-cells  do  not 
tend  to  collect  in  rouleux,  and  show  very  little  or  no  central  depres- 
sion, as  later  on.  The  number  of  red  blood-cells  is  not  only  greater 
to  the  cubic  millimetre  than  later  in  infancy,  but  the  ha3moglobin 
percentage  of  the  blood  and  of  the  individual  erythrocyte  is  much  higher 
than  later  on.  The  red  blood-cells  show  also  the  central  "  shadows  " 
to  a  greater  extent  than  is  seen  later  in  infancy.  The  white  cells  are 
present  in  larger  numbers  relative  to  the  red  blood-cells  than  later  in 
infancy,  and  this  proportion  is  still  greater  after  feeding. 

The  white  blood-cells  have  a  marked  tendency  also  to  group  them- 
selves in  clumps.  These  characteristics  of  the  blood  gradually  dis- 
appear toward  the  eleventh  day,  and  are  most  pronounced  on  the 
fourth  day  after  birth.  It  can  thus  be  seen  that  the  blood  picture 
obtained  during  the  first  days  of  life  is  such  as  would  be  of  grave 
pathological  import  if  found  in  the  adult. 

Digestive  Functions. — The  saliva  is  secreted  in  much  less  quan- 
tity in  the  newborn  than  later  in  infancy,  and  is  present  in  just  sufii- 
cient  amount  to  moisten  the  mucous  membrane  of  the  mouth.  Its 
reaction  is  slightly  alkaline,  but  in  disturbed  conditions  of  tho  mucous 
membrane  of  the  mouth  it  becomes  acid.  The  amylolytic  ferments 
are  present  only  in  the  secretion  of  the  parotid  gland,  and  here  only 
to  a  slight  degree.  The  secretion  of  the  submaxillary  gland  shows 
this  property  only  after  the  third  month  of  infancy  (Zweifel). 

Pepsin  is  found  in  the  stomach  of  the  embryo  at  the  fourth  month, 
whereas  hydrochloric  acid  is  found  in  this  organ  only  during  the  later 
months  of  foetal  life.  Both  are  present  in  tlie  stomach  of  the  new- 
born infant. 

The  pancreatic  secretion  in  the  newborn,  while  incapable  of  con- 
verting starch  into  sugar,  does  contain  trypsin  and  a  fat-splitting 
ferment. 

The  properties  of  the  secretions  of  the  mucous  membrane  of  the 
intestine  of  the  newborn  are  still  a  matter  of  speculation.  The  gall- 
bladder of  the  newborn  infant  contains  0.1  to  0.3  grammes  of  bile, 
which  is  increased  in  amount  after  the  ingestion  of  food.  The  bile 
contains  less  water  and  is  richer  in  .mucin,  coloring-matter,  and 
taurocholic  acid  in  the  newborn  infant  than  at  any  other  time  of  life. 
Glycocholic  acid  is  not  found  in  the  bile  of  the  newborn.  The  physio- 
logical function  of  the  bile  is  still  undetermined. 

From  the  above  it  will  be  seen  that  in  the  newborn  infant  the 
digestion  of  starchy  substances  is  but  feeble,  whereas  the  digestion  of 
fats  and  albuminoids  is  as  complete  as  in  later  infancy. 


170  DISEASES  OF  THE  NEWBORN. 

Body-temperature. — The  rectal  temperature  of  the  infant  taken 
immediately  after  birth  is  about  0.6°  C.  higher  than  that  of  the 
mother.  The  average  temperature  of  the  newborn  subsequent  to 
depressions  incident  to  the  immediate  postnatal  period  is  3Y.7°  C. 
(99.6°  F.).  Febrile  states  of  the  mother  at  the  time  of  parturition, 
or  external  influences,  may  cause  a  rise  or  fall  of  the  body-tempera- 
ture in  the  newborn.  Thus,  a  case  is  recorded  in  which  an  infant 
born  of  a  mother  suffering  from  fever  at  the  time  of  labor  had  a 
temperature  of  41°  C.  (105.8°  F.)  immediately  after  delivery 
(Lange,  Fehling).  Premature  or  congenitally  weak  infants  have  a 
lower  rectal  temperature  than  vigorous  full-term  infants.  An  hour 
or  two  after  birth  the  body-temperature  falls,  but  after  nine  to  seven- 
teen hours  attains  37°  C.  (98.6°  F.).  This  fall  may  be  as  much  as 
1.7°  to  2.5°  C,  and  is  due  to  the  cooling  influence  of  the  first  bath, 
the  change  from  the  warmth  of  the  uterine  cavity  to  the  external  air, 
and  the  respiration.  Toward  the  end  of  the  first  week  the  body- 
temperature  of  the  newborn  rises  slowly  to  the  permanent  normal  by 
tenths  of  a  degree.  In  the  congenitally  weak  the  temperature  rises 
more  slowly  and  reaches  37°  C.  after  twenty-four  hours;  whereas  in 
strong  and  well-developed  infants  it  reaches  this  limit  in  one-quarter 
to  one-half  this  time. 

The  temperature  of  the  newborn  is  more  easily  depressed  and 
raised  by  external  influences  than  that  of  the  adult.  Thus,  clothes 
and  the  surrounding  atmosphere  exert  a  marked  influence  in  this 
respect.  There  is  also  a  direct  relation  between  the  amount  of  nour- 
ishment ingested  and  the  body-temperature.  If  the  nutriment  is 
insufficient,  the  normal  temperature  is  attained  much  more  slowly 
than  under  contrary  conditions.  An  illustration  of  the  influence  of 
external  conditions  on  the  temperature  is  the  case  of  a  congenitally 
weak  infant  recently  brought  to  my  notice,  whose  temperature  was 
raised  fully  0.6°  C.  (1.5°  F.)  above  the  normal  by  placing  warm- 
water  bottles  too  near  the  body.  The  temperature  of  the  newborn, 
therefore  is  subject  to  wide  variations ;  but  it  may  be  said  that  after 
the  second  day  a  temperature  below  36°  C.  (96.8°  F.)  or  above  38° 
C.  (100.4°  F.)  is  abnormal.  The  diurnal  fluctuation  of  the  body- 
temperature  of  the  newborn  is  characteristic  in  that  the  highest  point 
in  the  curve  is  reached  in  the  early  morning  (6  a.  m.)  rather  than  in 
the  evening,  as  in  the  adult. 

Skin. — The  body  of  the  newborn  infant  is  covered  with  a  grayish, 
cheesy  material,  which  consists  of  epithelial  scales  and  secretions 
from  the  sebaceous  glands,  called  the  vernix  caseosa.  As  is  well 
known,  this  is  washed  off  after  birth,  and  leaves  the  skin  smooth  and 
of  a  uniform  pink  color.  The  skin  of  the  newborn  infant  desqua- 
mates in  small  and  large  scales.     This  is  distinctly  noticeable  at  the 


PHYSIOLOGY  OF  THE  NEWBORN.  171 

sixth  or  seventh  day,  and  ends  in  the  second  or  third  week  after  birth. 
Small  vesicles  are  seen  to  form  here  and  there  on  the  skin  over  the 
body  in  some  infants. 

The  body  at  birth  is  covered  with  soft,  long  hair  called  lanugo. 
This  is  also  found  on  the  scalp.  In  the  first  few  weeks  after  birth 
this  hair  falls  out  and  is  replaced  by  the  permanent  hair.  In  weak- 
lings this  replacement,  as  also  desquamation  of  the  skin,  takes  place 
more  slowly  than  in  stronger  infants.  In  the  first  few  weeks  the 
sebaceous  glands  are  especially  active,  and  their  activity  is  indicated 
by  the  appearance  of  the  so-called  scurf  on  the  scalp.  On  the  body, 
in  the  groin,  on  the  nose  and  face,  small  white  bodies  are  noticed  in 
the  newborn  infant,  called  milia.  Epstein  showed  that  these  were 
really  retention  cysts  of  sebaceous  follicles  of  the  skin.  They  dis- 
appear in  the  course  of  two  or  three  weeks. 

Jaundice. — The  skin,  though  pink  in  color  at  birth,  becomes  jaun- 
diced from  the  second  to  the  fourth  day  after  birth  in  80  per  cent, 
of  newborn  infants. 

Perspiration. — Although  infants  are  hardly  seen  to  perspire  pro- 
fusely unless  warmly  clothed,  the  insensible  perspiration  from  the 
skin  and  lungs  is  proportionately  greater  for  the  expanse  of  the  body 
surface  than  in  the  adult.  Rubner  and  Heubner  showed  that  the 
infant  yielded 

During  the  first  week  fully  90  grammes  (3  ounces) ; 

"         "     second  and  third  months  192  grammes  ( 6 J  ounces)  ; 

"         "     fifth  and  sixth  "         290  grammes  (9f  ounces) ; 

"         "     fii"st  year  460  gi-ammes  (15^  ounces) 

of  insensible  perepiration  daily,  as  compared  with  650  grammes  (21f 
ounces  of  the  adult. 

Breasts. — From  the  third  to  the  fifth  day  after  birth  milk  appears 
in  the  breasts  of  the  newborn  infant  of  both  sexes.  As  a  rule,  the 
secretion  appears  earlier  in  the  breasts  of  girls  than  in  boys.  The 
breasts  become  swollen  and  tense ;  one  gland,  generally  the  right, 
functionating  sooner  than  the  other.  The  cause  of  this  curious 
phenomenon  is  as  yet  unknown.  Balantyne  suggests  that  it  is  due 
to  a  bio-chemical  relation  between  the  foetus  and  the  mother,  which 
exercises  its  influence  on  the  infant  after  birth  in  such  a  way  that 
the  same  agencies  which  cause  a  production  of  milk  in  the  mother 
continue  to  produce  the  same  result  in  the  infant.  The  secretion  has 
been  examined  by  Barfurth,  Herz,  and  others,  and  has  been  found  to 
be  composed  of  proteids,  2.5  to  2.6  per  cent.;  fat,  2.3  to  3  per  cent.; 
sugar,  2.5  per  cent.  It  is  therefore  a  real  secretion  of  milk,  and  the 
method  of  its  secretion  is  the  same  as  in  the  adult  gland.  The 
amount  of  milk  which  is  called  by  the  laity  "  witches'  milk,"  is  small. 


172 


DISEASES  OF  TEE  NEWBORN. 


The  secretion  lasts,  as  a  rule,  from  six  to  eight  weeks ;  in  exceptional 
cases  it  may  continue  six  months  (Herz).  If  mastitis  occur,  it  is 
certainly  the. result  either  of  antepartum  or  postpartum  infection,  and 


not'of  caking  of  the  breasts. 


Fir;.  26. 


Caking  of  the  milk  in  both  breasts  of  a  newborn  infant. 


Urine. — Speaking  of  the  urine  of  the  newborn  in  a  stricter  sense, 
the  amount  passed  spontaneously  after  birth  is  on  the  average  9.6 
c.c,  of  which  7.5  c.c.  may  be  found  in  the  bladder  at  the  time  of 
birth,  unless  the  viscus  has  been  subjected  to  pressure  during  birth. 
The  urine  is  passed  spontaneously  within  twenty-four  hours  after 
birth  in  66  per  cent,  of  newborn  infants,  and  in  the  remaining  cases 
within  forty-eight  hours  after  birth. 

Quantity. — The  daily  quantity  of  urine  during  the  first  two  weeks 
varies  widely  according  to  different  observers.  On  an  average  the 
amount  varies  in  breast-fed  and  bottle-fed  infants  according  to  the 
amount  of  fluid  food  ingested.  In  breast-fed  infants  the  amount 
during  the  first  three  days  increases  from  17  c.c.  to  43  to  40  c.c,  and 


PHYSIOLOGY  OF  THE  NEWBORN.  173 

on  the  fourth  day  amounts  to  116  c.c,  due  to  an  increase  of  milk  in 
the  mother's  breast.  On  the  fourteenth  day  the  amount  has  rnn  up 
to  263  c.c. 

Hofmeier  and  Schiff  have  shown  that  infants  in  whom  the  cord 
has  been  tied  early,  and  in  whom  the  gross  amount  of  blood  in  circu- 
lation is  less  than  in  those  in  whom  the  cord  has  been  tied  late,  the 
daily  quantity  of  urine  will  be  proportionately  less.  As  soon  as  a 
constant  relationship  is  established  between  the  amount  of  fluid  taken 
into  the  body  and  that  excreted,  toward  the  seventh  day,  then  the 
amount  of  urine  excreted  reaches  the  proportionate  relationship  to 
the  body-weight  that  exists  in  the  adult.  Thus,  whereas  on  the  first 
day  21.8  to  38.8  per  cent,  of  the  milk  taken  is  excreted  in  the  form 
of  urine  (Cruse,  Reusing),  on  the  eighth  day  it  reaches  the  constant 
proportion  of  62.8  per  cent.,  as  in  the  adult.  The  amount  of  urine 
proportionate  to  each  kilogramme  of  body-weight  must  necessarily 
increase  more  markedly  during  the  first  eight  days,  inasmuch  as, 
while  the  body-weight  during  this  time  is  more  or  less  stationary,  the 
gross  amount  of  urine  increases.  Thus,  the  first  day  it  amounts  to 
5.9  c.c.  to  each  kilogramme;  on  the  eighth  day  it  reaches  6Y.4  c.c, 
on  the  tenth  day  90  c.c,  and  then  remains  stationary.  These  figures 
are  higher  than  is  true  of  the  adult,  in  whom  the  daily  amount  of 
urine  per  kilogramme  of  body-weight  is  25  c.c 

Color. — The  urine  of  the  newborn  is  almost  colorless ;  its  specific 
gravity  in  the  foetus  is  1002.8  (Dohrn)  ;  in  the  first  two  days  of  life 
1008  to  1009,  on  the  third  day  1011  to  1013,  and  on  the  tenth  day  it 
falls  to  1003  to  1004.  In  bottle-fed  infants  the  specific  gravity  is 
lower  than  in  the  breast-fed  infant,  due  to  the  increased  amount  of 
milk  ingested.  The  reaction  of  the  urine  of  the  newborn  is  con- 
stantly acid  in  all  but  3  per  cent.  (Hofmeier).  The  urine  of  new- 
born infants  during  the  first  five  days  of  life  contains  renal  epithe- 
lium, uric-acid  crystals,  amorphous  urates,  and  frequently  casts. 
Hyaline  and  granular  casts  were  found  by  Reusing  in  39.4  per  cent, 
of  breast-fed  and  in  9  per  cent,  of  bottle-fed  infants  during  the  first 
days  of  life.     If  casts  are  present,  there  is  also,  as  a  rule,  albumin. 

Urea. — The  amount  of  urea  increases  absolutely  and  relatively 
from  the  first  day  of  life.  Thus,  it  increases  in  absolute  quantity 
from  0.06  to  0.11  the  first  day,  to  0.82  on  the  eleventh  day,  or,  rela- 
tively to  each  kilogramme  of  body-weight,  0.018  to  0.29  on  the 
seventh  day. 

Uric  Acid. — Uric  acid  is  present  in  the  urine  of  the  newborn  in 
remarkably  large  amounts.  Thus,  on  the  first  day  the  urine  contains 
0.0136  of  uric  acid  to  each  kilogramme  of  body-weight.  That  is 
much  greater  than  in  the  adult.  The  proportion  of  uric  acid  to  urea 
is  much  greater  in  the  newborn  than  at  any  other  period  of  life;  in 


174  DISEASES  OF  THE  NEWBOBN. 

the  adult  it  reaches  the  high  relative  percentage  of  the  newborn  only 
in  pathological  states.  Thus,  in  the  adult  the  relative  proportion  of 
uric  acid  to  urea  is  as  1 :  41  or  61,  whereas  in  the  newborn  it  ranges 
from  1 : 1.5  on  the  first  day  to  1 :  21.9  on  the  seventh  day  of  life. 

Albumin. — Albumin  is  found  immediately  after  birth  in  the  urine 
in  38  per  cent,  of  infants  (Dohrn).  Dohrn  ascribes  its  presence  as 
due  to  complications  during  birth  or  disturbances,  however  slight, 
of  the  circulation.  Hofmeier  found  it  disappeared  toward  the  end 
of  the  first  week ;  also  that  there  was  a  constant  relationship  between 
the  excretion  of  uric  acid  and  the  presence  of  albumin  in  the  urine 
of  the  newborn,  the  latter  being  absent  in  those  cases  in  which  uric 
acid  was  not  found  and  in  which  no  uric  acid  infarction  of  the  kidney 
existed.  He  attributed  the  albuminuria  of  the  newborn  to  the  me- 
chanical irritation  of  the  deposits  of  uric  acid  on  the  epithelium  of 
the  uriniferous  tubules. 

Rectal  Excreta. — Meconium. — Meconium  forms  the  gut  content 
in  the  foetus.  It  is  of  a  yellowish-green  color  in  the  small  intestines 
— of  a  dark-green  color  in  the  large  gut,  becoming  lighter  after  an 
interval  of  a  day  or  so  after  birth.  It  is  of  a  tarry  consistence  and 
odorless.  The  total  quantity  of  meconium  varies  from  TO  to  90 
grammes,  or  2^  to  3  ounces,  of  which  2  to  20  grammes  are  passed 
daily.  When  the  infant  takes  the  breast  or  cows'  milk,  meconium 
is  mingled  in  the  movements  with  the  milk  faeces.  The  first  pas- 
sage of  meconium  occurs  immediately  after  or  in  the  first  few  hours, 
at  the  latest  ten  to  twelve  hours,  after  birth,  and  is  preceded  by  the 
expulsion  of  the  so-called  meconium  plug.  This  is  a  body  of  mucoid 
tissue  2  millimetres  in  diameter,  and  is  of  importance  in  a  medico- 
legal sense.  An  infant  stillborn  will  retain  in  the  lower  part  of  the 
rectum  the  meconium  plug. 

The  stools  for  the  first  two  days  consist  mostly  of  meconium, 
which  subsequently  becomes  mingled  with  the  milk  fseces.  The  move- 
ments contain  both  yellow  and  greenish  residue.  After  the  fourth 
day  the  infantile  movements  assume  their  permanent  characteristics 
of  color  and  consistence.  The  composition  of  meconium  has  been 
fully  investigated.  It  is  made  up  of  desquamated  epidermal  and 
intestinal  epithelium,  amniotic  fluid,  vernix  caseosa,  wool-hair  or 
lanugo,  plates  of  cholesterin,  scales  of  skin,  hsematoidin  crystals,  bili- 
rubin, fat-drops,  and  stearic-acid  crj'stals.  Bilirubin  is  peculiar  to 
meconium  (Zweifel  and  Schmidt).  Weintraud  found  uric  acid  and 
alloxur  bases  in  meconium,  which  were  probably  derived  from  a 
nuclein  substance.  Schild  found  that  sterile  meconium  contained  a 
peptonizing  ferment;  and  Patevin  found  a  lab-ferment  and  amylase 
in  sterile  meconium. 

Meconium  contains  also  the  characteristic  so-called  "meconium 


PHYSIOLOGY  OF  THE  NEWBOBN.  175 

bodies."  These  consist  of  ovoid  or  polyhedral  masses  yellowish- 
green  in  color.  They  are  made  up  of  organic  matter,  such  as  masses 
of  intestinal  epithelium  and  mucus,  in  which  are  precipitated  biliary 
pigments  and  salts.  They  contain  biliary  pigment,  soluble  in  caustic 
potash,  insoluble  in  ether  or  acetic  acid. 

Chemical  analysis  of  meconium  reveals  mucin,  palmitin,  stearin, 
olein,  biliary  pigments,  and  taurocholic  acid.  It  does  not  contain 
indol  or  phenol,  which  are  products  of  decomposition. 

During  the  first  few  days  of  infancy  the  stools  contain  much 
mucus  of  a  stringy  character,  and  the  writer  has  frequently  seen 
this  actually  drawn  out  of  the  rectum  in  shreds  by  the  nurse  in 
otherwise  normal  infants. 

Bacteria. — Meconium  is  sterile  at  first,  and  then  becomes  infected 
with  bacteria  in  from  three  to  eighteen  hours  after  birth.  A  proteus 
similar  to  that  of  Hauser's  is  regularly  found,  also,  a  chain  coccus 
and  a  Bacillus  subtilis.  With  the  appearance  of  the  milk  faeces,  a 
bacillus  similar  to  that  of  the  Bacillus  lactis  aerogenes  is  found  in 
the  upper  part  of  the  gut,  the  colon  bacillus  in  the  lower  portion  with 
the  coccobacillus  of  Fischl. 

Nervous  System. — The  nervous  system  is  not  in  an  active,  but 
rather  in  a  receptive,  state  in  the  newborn. 

Muscular  power  as  well  as  muscular  sense  is  but  little  developed. 
The  newborn  infant  can  neither  sit  up  nor  hold  its  head  upright. 
The  reflex  irritability  of  nerve  and  muscle  both  to  galvanic  or  faradic 
stimulus  is  less  evident  in  the  newborn  than  later  in  infancy  or  in 
the  adult.  Response  to  stimulation  is  distinctly  delayed;  the  latent 
period  is  more  marked  in  the  newborn.  In  the  newborn  the  inhibi- 
tory functions  of  the  vagus  are  not  fully  developed,  but  it  is  sus- 
ceptible to  reflex  action,  as  is  demonstrated  in  cases  of  cerebral 
pressure  with  slowed  pulse  due  to  injury  incident  to  birth.  In  these 
cases  the  vagus  would  seem  to  exert  through  the  cerebral  centres  an 
inhibitory  influence  on  the  heart.  The  cerebrum  seems  to  be  in  a 
passive  rather  than  in  an  active  state  in  the  newborn.  In  spite  of 
the  divergence  of  views,  there  seems  to  be  no  sign  of  consciousness  in 
the  newborn,  nor  are  the  motor  centres  developed  to  such  an  extent 
as  to  react  under  stimulus.  Motion  is  rather  of  a  reflex  nature  or 
indirectly  referable  to  the  high  development  of  the  sense  of  touch. 
Thus,  we  m.eet  with  injuries  of  the  skull-cap  in  the  newborn  which 
are  of  an  extensive  character,  such  as  depression  of  the  skull,  giving 
no  symptoms  referable  to  the  motor  areas.  On  the  other  hand,  there 
is  sufficient  reason  to  believe  that  the  cerebrum  exerts  a  negative 
inhibitory  influence,  and  that  several  of  such  centres  are  active  in  the 
newborn.  The  skin  reflex  presents  nothing  peculiar  in  the  newborn. 
The  patellar  reflex  is  somewhat  increased,  diminishing  after  the 
seventh  to  the  nineteenth  day. 


176  DISEASES  OF  THE  NEWBORN. 

Ill  spite  of  the  assertions  of  Kiissmaiil  and  Preyer.  as  to  the 
existence  of  the  sense  of  taste  in  the  newborn,  there  is  reason  to 
believe  that  this  sense  is  but  little  developed,  and  really  exists  in 
the  nature  of  a  reflex  rather  than  a  sense  which  distinguishes  between 
sweet,  bitter,  and  sour,  as  in  the  adult  (Gensmer).  Thus,  Lauge 
has  given  a  4  per  cent,  quinine  solution  to  the  newborn  without 
awakening  any  signs  as  to  the  appreciation  of  its  bitter  taste.  It 
is  also  questionable  whether  the  newborn  appreciates  the  sweet  taste 
of  breast  milk.  On  the  whole,  it  may  be  said  that  it  takes  a  strong 
solution  of  any  kind,  sweet  or  bitter,  to  cause  any  visible  reaction  in 
the  newborn,  and  that  this  reaction  is  rather  in  the  nature  of  a  gen- 
eral reflex  than  an  appreciation  of  differences  of  sweet,  sour,  or  bitter. 

Hearing  is  not  evident  as  a  sense  immediately  after  birth,  and, 
as  has  been  pointed  out  elsewhere,  the  newborn  infant  is  deaf.  The 
sense  of  hearing  develops  at  various  periods  after  birth,  from  six  to 
forty-eight  hours,  according  to  the  rapidity  with  which  in  the  new- 
born the  Eustachian  tube  is  opened  up  and  air  enters  the  internal  ear. 
In  prematurely  born  infants,  on  account  of  marked  swelling  of  the 
walls  of  the  tube,  the  development  of  the  sense  of  hearing  is  much 
delayed.  These  facts  explain  the  wide  difference  among  observers 
(Kussmaul,  Preyer,  Gensmer)  as  to  the  development  of  this  sense. 
Gensmer  is  probably  correct  when  he  says  that  most  infants  react  to 
sound  after  the  first  or,  at  least,  the  second  day.  The  improvement 
in  the  hearing  is  unmistakable  in  the  first  week. 

In  the  premature  as  well  as  in  infants  born  at  full  term,  the  eye 
reflexes  are  developed.  Thus  the  pupil  contracts  and  dilates  under 
stimulus,  and  intense  light  or  continued  flashing  of  light  in  the 
vicinity  of  the  newborn  calls  forth  sigiis  of  general  reflex  irritability ; 
that  is,  the  newborn  becomes  uneasy  under  irritation  of  this  nature. 
It  is  still  a  matter  of  discussion  as  to  whether  the  newborn  can  fix 
or  focus  objects  and  whether  accommodation  is  developed.  The 
eyelids  react  promptly  to  reflex  stimulus. 

The  sense  of  smell  is  but  slightly  developed  in  the  newborn,  and 
it  is  a  matter  of  question  as  to  whether  at  this  time  the  infant  may 
recognize  the  mother  or  the  nipple  of  the  breast  by  meaus  of  this 
sense.  Par  more  probable  is  it  that  in  this  respect  the  sense  of 
touch  and  its  reflexes  has  been  mistaken  in  its  manifestations  for 
that  of  smell. 

The  sense  of  touch  is  the  most  highly  developed  sense  in  the  new- 
born, and  is  most  evident  in  the  lips  and  face.  The  Mx)  reflex  is 
especially  developed,  inasmuch  as  in  the  newborn  the  least  contact 
of  any  object  with  the  lips  calls  forth  the  pursing  of  the  lips  and  the 
motions  attendant  upon  suckling. 

The  appreciation  of  pain  is  absent  immediately  after  birth,  and 


FH¥SIOLOGY  OF  THE  NEWBORN.  177 

only  after  one  or  two  days  does  the  newborn  react  to  the  irritation 
of  a  pin-point. 

But  little  is  known  of  the  appreciation  of  heat  and  cold  in  the 
newborn;  and  it  may  be  said  that  these  call  forth  only  manifesta- 
tions of  a  general  reflex  action  as  is  seen  in  cases  of  asphyxia  when 
infants  are  brought  rapidly  from  the  warm  to  the  cold  plunge. 

Metabolism.- — Though  much  is  still  to  be  learned  as  to  the  proc- 
esses of  metabolism  in  the  newborn,  there  are  certain  facts  as  to  the 
daily  quantity  of  milk  taken,  the  amount  of  urine  voided,  the  loss  of 
weight  by  means  of  the  skin  and  faeces,  which  have  been  determined 
within  certain  limits. 

The  amount  of  milk  consumed  daily  by  the  newborn  has  been 
carefully  determined  by  weighing  the  infant  before  and  after  nursing. 
A  well-developed  infant  nursing  a  normally  secreting  breast  will, 
according  to  the  investigations  of  Cammerer,  Hahner,  and  Laure, 
consume  the  following  quantities  of  milk,  expressed  in  cubic  centi- 
metres : 

Days  1    2   3   4   5    6    7    8    9   10   11   12   13   14   15 
33  123  209  290  305  342  400  417  426  413  441  437  516  487  536 

Excretion  and  Waste, — Meconium  and  Faeces. — As  long  as  me- 
conium is  voided  the  movements  are  small.  As  soon  as  milk  fseces 
appear  they  average  1  to  3  grammes  of  fseces  to  100  c.c.  of  milk 
ingested.  An  infant  during  the  first  two  weeks  rarely  voids  more 
than  10  grammes  of  fseces  daily.  The  excretion  of  carbonic-acid  gas 
and  water  by  the  skin  and  lungs  has  as  yet  not  been  accurately  deter- 
mined. The  experiments  of  Forster  as  to  the  excretion  of  carbonic- 
acid  gas  were  performed  on  a  fourteen-day-old  infant.  His  observa- 
tions were  made  on  the  sleeping  infant  only,  also  a  source  of  error. 
Cammerer,  however,  determined  the  daily  exhalation  by  lungs  of 
carbonic-acid  gas  more  definitely,  and  found  that  this  was  as  follows : 

1st  day.  2d  day.  3d  day.         End  1st  week.         End  2d  week. 

100  grammes     85  grammes     80  grammes     100  grammes     130  to  150  grammes 

It  may  be  said  that  under  similar  conditions  the  newborn  infant 
exhales  more  carbonic-acid  gas  per  kilogramme  of  body-weight  than 
the  adult. 

Though  certain  facts  as  to  the  metabolic  processes  are  as  yet  unde- 
termined in  the  newborn,  we  can  still  form  an  approximate  estimate 
as  to  the  ultimate  disposition  of  the  food  and  the  manner  in  which 
oxidation  processes  of  the  body  are  carried  out  in  the  first  few  days 
of  life.  Thus  Cammerer  has  by  estimating  the  amount  of  food 
ingested,  and  the  amount  of  urine,  fseces,  and  carbonic-acid  gas 
excreted,  drawn  up  a  very  instructive  table  showing  the  loss  of  weight 

12 


178 


DISEASES  OF  THE  NEWBOBN. 


and  the  manner  in  which  it  is  kept  within  certain  limits  during  the 
first  four  days  of  life : 


Day. 


Milk  taken. 


Excreted. 


Loss  of  weight. 


10.0 


91.5 


247.0 


337.0 


Urine 48.0 

Meconium 51.0 

Co, 96.0 

195.0 

Urine 53.0 

Meconium 23.0 

Faeces 3.0 

C02. 84.5. 

163.5 

Urine 172.0 

Fseces 3.0 

C02 82.0 

257.0 


Urine 226.0 

Ffeces 2 

C02 

322.0 


.o-| 

.5J 


185 


72 


10 


+  15 


Thus,  the  loss  of  weight  during  the  first  four  days  is  due  in  great 
part  to  the  lack  of  sufficient  nourishment  to  compensate  for  the  loss 
through  the  urine  and  fseces. 

In  order  to  illustrate  more  completely  the  oxidation  processes 
in  the  body,  Cammerer  has  reduced  the  food  and  excreta  to  their 
chemical  elements.     The  C,  H,  IsT  and  O  taken  into  the  body  in  the 


Infant  Fourteen  Days  Old,  Weighing  3500  Grammes. 


Taken  into  the  body  in 
twenty-four  hours. 

Water. 

C. 

H. 

N. 

0. 

Ash. 

Milk 

Inspired  0.  .        .    . 

500.0 

70.2 

444.0 

29.5 

4.5 

49.3 

2.0 

18.4 

70.2 

394.7 

1.6 

444.0 

Urine  voided  .    .    . 

Fseces 

C02 

570.2 

350.0 

7.0 

185.1 

444.0 

347.0 

5.0 

104.1 

29.5 

0.7 

0.8 

22.0 

53.8 

0.1 
0.1 

50.7 

2.0 

1.0 
0.1 

483.3 

0.7 

0.3 

59.0 

405.4 

1.6 

0.5 
0.7 

456.1 

Balance  in  favor  of 
increase  of  weight 

542.1 

456.1 

28.1 

23.5 
6.0 

50.9 

2.9 

1.1 

0.9 

465.4 
179 

1.2 

0.4 

form  of  nourishment  and  inhaled  oxygen  are  compared  to  the  same 
elements  excreted  in  the  urine,  fa3ces,  and  the  expired  air.  It  is  seen 
that  in  the  newborn,  as  in  the  adult,  fully  93.4  per  cent,  of  the  carbon 


MORTALITY  AND  SUDDEN  DEATH  IN  THE  NEWBORN.  1  79 

taken  in  is  excreted  in  the  carbonic-acid  gas,  the  nitrogen  being 
excreted  for  the  most  part  in  the  urine.  Whereas,  however,  in  the 
adult  the  nitrogen  taken  in  is  excreted  entirely  in  the  urine  and 
feces ;  in  the  newborn  fully  half  the  nitrogen  is  retained  in  the  body. 
The  student  may  thus  see  that  the  loss  of  weight  during  the  first 
few  days  is  considerable.  It  has  not  as  yet  been  accurately  deter- 
mined whether  an  infant  nursed  from  the  first  day  of  life  on  a  breast 
secreting  abundant  milk  would  lose  weight  similar  to  that  of  the 
newborn  nursed  on  the  mother's  breast.  It  is  well  known  that  the 
loss  of  weight  is  greater  in  those  fed  on  a  substitute  than  on  the 
breast.  The  further  details  of  loss  and  increase  of  weight  will  be 
found  under  the  heading  of  Infant-feeding. 

MORTALITY  AND    SUDDEN   DEATH   IN    THE   NEWBORN. 

Sudden  death  is  not  uncommon  in  the  first  week  of  life,  and, 
according  to  Snow,  fully  one-tenth  of  the  race  succumb  in  the  first 
month  of  existence.  Modern  methods  have  tended  to  reduce  this 
startling  mortality,  but  the  conditions  attending  the  birth  of  the 
infant  are  such  that  there  will  always  be,  independent  of  sepsis  of 
any  kind,  a  quota  of  the  newborn  which  will  succumb,  either  with 
previous  symptoms  or  suddenly,  in  the  first  week  or  first  month  of 
existence.  Eross  has  found  that  9-J  per  cent,  of  all  children  born  in 
Europe  died  in  the  first  four  weeks  of  life.  Of  these  37  per  cent, 
died  in  the  first  week,  29  per  cent,  in  the  second,  21  per  cent,  in  the 
third,  and  13  per  cent,  in  the  fourth  week. 

The  statistics  of  the  different  countries  vary,  as  one  would  nat- 
urally expect,  according  to  the  methods  of  midwifery  in  vogue.  It 
is  of  interest,  however,  that,  in  the  United  States,  Snow,  of  Buffalo, 
has  collected  some  statistics  on  this  subject  in  his  own  city.  Of  7290 
births  471  died  during  the  first  month.  Thus  6.4  per  cent,  of  all  the 
children  born  in  Buffalo  died  during  the  first  four  weeks,  a  death 
rate  of  9.3  per  cent,  of  the  total  mortality. 

If  we  look  for  the  causes  of  mortality  in  early  life  we  may  class 
them  grossly  under  those  due  to  (1)  immaturity  or  congenital  weak- 
ness, with  or  without  syphilis;  (2)  malformations  which  are  fatal  in 
themselves;  (3)  asphyxiation  and  atelectasis;  (4)  injuries  sustained 
during  parturition,  such  as  apoplexies,  both  cephalic  and  abdominal ; 
(5)  septic  infections  of  various  kinds.  The  effect  of  prolonged  and 
difficult  labor,  abnormal  presentations,  the  application  of  forceps, 
may  cause  a  cerebral  hemorrhage,  especially  in  premature  or  con- 
genitally  weak  infants,  but  a  difficult  labor  is  not  necessarily  an 
etiological  factor  in  these  cases,  for  cerebral  hemorrhages  occur  in 
infants  who  have  passed  through  an  apparently  normal,  or  even  a 


180  DISEASES  OF  THE  NEWBORN. 

precipitate,  labor.  It  seems  that  in  these  cases  simple  pressure  of 
the  parts  in  the  parturient  canal  precipitates  a  hemorrhage  which, 
subsequent  to  birth,  attains  an  extent  which  is  fatal. 

Spencer  found  that  of  130  infants  dying  in  the  first  few  hours  of 
life,  65  per  cent,  of  deaths  were  due  to  injuries  sustained  by  the 
brain  in  the  form  of  congestion  and  hemorrhages,  and  he  considers 
the  forceps,  next  to  abnormal  presentations,  such  as  foot  and  breech, 
as  the  most  frequent  etiological  factor  in  producing  hemorrhage. 

Hemorrhage  and  apoplexies  of  fatal  character  may  occur  in  the 
liver,  suprarenal  capsule,  and  lung,  and  many  children  subject  to 
cerebral  hemorrhages  succumb  to  convulsions  in  the  first  hours  of 
existence.  It  must  not  be  forgotten,  however,  that  the  most  trying- 
cases  of  sudden  death  in  the  newborn  are  those  in  which  infants 
are  born  after  a  labor  in  every  respect  normal,  and  who  at  birth 
present  absolutely  nothing  abnormal  physically  to  the  careful  and 
practised  eye,  and  who  continue  in  apparent  health  for  twenty- 
four  hours  to  a  week,  with  sudden  death  as  an  outcome.  These 
cases  present  absolutely  no  symptoms  to  warn  the  physician  of 
the  approaching  catastrophe.  They  may  nurse  in  a  regular  man- 
ner, apparently,  the  bowels  may  appear  natural  in  color  and  con- 
sistence, and  even  after  the  death  of  the  infant  an  inquiry  into  the 
clinical  history  of  the  case  fails  to  reveal  any  symptom  which  might 
lead  to  the  detection  of  the  trouble.  These  cases  post-mortem  may 
reveal  a  cerebral  hemorrhage  or  an  abdominal  umbilical  hemor- 
rhage, which  previously  revealed  but  few  symptoms.  I  recently  saw 
such  a  case  in  a  premature  child,  born  rather  precipitately,  which 
continued  well  and  in  perfect  condition  for  twenty-four  hours,  then 
suddenly  developed  cyanosis,  attacks  of  respiratory  apnoea,  and  died 
within  a  few  hours.  In  this  case  nothing  was  revealed  post-mortem 
but  a  slight  atelectasis  of  the  lung.  Another,  in  which  an  infant 
nursed  on  the  breast  of  a  wet-nurse  for  six  days,  did  not  lose  weight, 
but  rather  held  its  own,  nursed  vigorously  a  few  hours  before  death, 
cried  but  little,  slept  most  of  the  time,  and  was  found  dead  in  bed, 
with  a  slight  hemorrhage  from  the  nose,  on  the  sixth  day.  This,  in 
all  likelihood,  was  a  case  of  unrecognized  sepsis  of  the  newborn. 

In  the  newborn  all  cases  do  not  die  suddenly.  There  is  in  most 
cases  marked  or  slight  warning,  extending  over  days  or  hours  before 
the  fatal  issue.  There  may  be  signs  of  cerebral  irritation,  but  these, 
as  a  rule,  come  on  suddenly  in  severe  cases.  Some  time,  hours  or 
days,  after  birth,  the  child  may  be  attacked  with  cyanosis,  it  may 
whine  or  cry  without  apparent  cause,  there  may  be  derangement  of 
the  respirations,  irregnilarly  slow  pulse;  there  may  be  a  series  of  con- 
vulsions, which  may  end  the  scene  or  which  may  continue  for  days. 
Sometimes  a  slight  hemorrhage  gives  rise  to  no  symptoms  at  all  until 


CONGENITAL  ANOMALIES.  181 

later  in  life,  so  that  we  cannot  say  that  hemorrhage  always  causes 
death  in  the  newborn. 

If  meningeal  hemorrhage  is  preceded  by  the  symptoms  such  as 
have  been  detailed,  a  diagnosis  can  be  made,  but  in  cases  in  which 
these  symptoms  are  absent  clinical  diagnosis  is  impossible.  As- 
phyxia, atelectasis,  and  compression  of  the  cord  cause  a  mortality 
of  3.6  per  cent,  of  the  total  number  of  deaths  in  the  newborn.  In 
congenital  atelectasis  there  may  have  been  an  easy  labor,  but  inherent 
weakness  and  immaturity  of  the  respiratory  muscles  may  cause 
imperfect  expansion  of  the  lungs. 

A  large  proportion  of  deaths  in  the  newborn  infant  are  the  result 
of  sepsis.  The  pathogeny  and  symptomatology  of  sepsis  will  be  con- 
sidered under  the  proper  heading,  but  some  of  the  severest  forms  of 
sepsis,  resulting  in  arteritis  of  the  umbilical  arteries  or  in  a  general 
bacterial  invasion,  give  absolutely  no  symptoms  and  result  in  sudden 
death.  The  conditions  at  this  time  of  life  are  particularly  favorable, 
as  has  been  repeatedly  pointed  out  in  these  pages,  to  the  invasion  of 
germs,  and  the  avenues  of  infection  are  various,  as  has  been  dilated 
upon  in  the  chapter  on  Sepsis  in  the  l^ewborn.  ISTot  only  is  the 
resistance  almost  nil,  but  the  progression  of  the  disease  is  unhampered 
by  such  conditions  as  leucocytosis,  which  obtain  later  in  life,  for  lack 
of  leucocytic  reaction  and  deficient  development  of  the  lymphatic 
apparatus  is  especially  characteristic  of  this  period  of  life. 

In  addition  to  sepsis,  sudden  death  in  the  newborn  may  be  due 
to  forms  of  respiratory  disease,  such  as  bronchitis  and  pneumonia, 
which  have  not  only  escaped  observation,  but  which  give  absolutely 
no  symptoms  before  the  fatal  issue  supervenes,  and  are  only  revealed 
on  the  postmortem  table.  Such  infections  have  been  dilated  upon 
elsewhere.  They  may  originate  in  foul  atmosphere,  unclean  bedding, 
aspiration  of  amniotic  fluid,  and  as  a  result  of  this,  contamination 
by  colon  bacillus,  staphylococci,  and  streptococci.  We  will  not  enlarge 
upon  the  other  forms  of  sepsis  of  the  gastro-enteric  type,  but  will 
leave  that  for  future  consideration  in  the  chapter  on  Sepsis.  Sudden 
death  in  the  newborn,  due  to  hypertrophy  of  the  thymus,  is  a  rarity. 

CONGENITAL    ANOMALIES. 

Anomalies  of  the  Scrotum. — The  scrotum  may  be  divided  into 
halves,  separated  comjDletely  from  each  other,  each  with  its  contained 
testis.  There  are  rarely  more  than  two  testes.  There,  may  be 
accompanying  abnormalities,  such  as  circumscribed  hydrocele  of  the 
cord,  lipoma  fibrosum,  and  omental  structures.  Anorchidie  is  a  con- 
dition of  rudimentary  or  lacking  testis  and  adnexa  mostly  unilateral. 
Ectopia  testis  abdominalis  is  a  condition  in  which  the  testis  is  found 


182  DISEASES  OF  THE  NEWBOBN. 

■underneath  the  skin  of  the  abdomen.  Ectopia  cniralis  testis  is  a 
condition  in  which  the  testis  is  found  at  the  femoral  ring,  generally 
with  a  hernia.  Ectopia  perinealis  testis  is  a  condition  in  which  the 
testis  is  found  in  the  perineum. 

Retentio  Testis. — Eetentio  testis  refers  to  those  cases  in  which  the 
testis  remains  in  the  abdominal  cavity  or  in  some  part  of  the  inguinal 
canal. 

Retentio  abdominalis  refers  to  the  retention  of  the  testis  in  the 
abdomen. 

Eetentio  iliaca,  near  the  internal  ring. 

Retentio  inguinalis  refers  to  the  testis  retained  in  the  canal  or 
near  the  external  ring. 

Double  retention  is  also  called  cr jptorchism ;  single  retention  is 
spoken  of  as  monorchism. 

These  congenital  conditions  are  quite  commoir  in  children,  but 
disappear,  as  a  rule,  toward  the  age  of  puberty.  The  cause  of  the 
congenital  anomalies  is  a  lack  of  development  or  peritoneal  adhesions, 
and  their  principal  interest  clinically  lies  in  the  fact  that  they  may 
be  confounded  with  hernia  of  an  inguinal  type.  The  retained  testis 
of  the  inguinal  variety  is  apt  also  to  atrophy,  inasmuch  as  it  is  easily 
exposed  to  traumatism.  Kocher  has  shown,  also,  that  it  is  more  apt 
to  be  the  seat  of  new  growths,  especially  carcinoma. 

Diagnosis. — The  diagnosis  of  retained  testis,  especially  of  the 
inguinal  variety,  is  not  difficult.  The  mother  will  invariably  call 
attention  to  the  absence  of  the  testis  from  its  usual  situation.  Exami- 
nation of  the  scrotum  mil  reveal  its  absence  either  on  one  or  both 
sides.  By  invaginating  the  scrotum  through  the  inguinal  canal,  the 
physician,  as  a  rule,  will  find  the  testis  in  some  part  of  the  canal  or 
at  the  internal  opening  in  the  abdomen  as  a  small  globular  body. 
Tracing  the  location  of  the  testis,  its  absence  from  the  scrotum  and 
its  presence  in  the  abnormal  position  mentioned,  differentiates  it 
from  a  lymph  node  or  a  hernia.  Hernia  as  a  result  of  coughing  or 
exertion,  such  as  crying,  will  descend  and  increase  in  size  or  pro- 
trude from  the  external  ring.  'Not  so  with  the  testis.  It  may  even 
retract  higher  if  pain  is  experienced. 

Treatment. — There  is  no  treatment  for  this  condition,  although 
the  French  advise  the  systematic  pushing  down  of  the  testis  into  the 
scrotum  at  certain  intervals  up  to  the  age  of  puberty. 

Hydrocele  Congenita  or  Adnata. — This  anomaly  of  the  congeni- 
tal type  is  caused  by  a  lack  of  closure  of  the  peritoneal  fold,  the  pars 
vaginalis  peritonei.  There  is  a  communication  of  the  cavity  of  the 
tunica  vaginalis  Avith  the  peritoneal  cavity  to  a  greater  or  less  extent. 
Serous  fluid  of  the  peritoneal  cavity  may  gravitate  to  the  cavity  of  the 


TRE  CON  GEN  IT  ALLY  WEAK.  183 

tunica  vaginalis ;  or  ttere  may  be  a  free  opening  into  the  peritoneal 
cavity,  allowing  a  reposition  of  the  fluid.  In  such  cases  the  anomaly 
is  apt  to  be  confounded  with  inguinal  hernia.  The  communication 
with  the  peritoneal  cavity  may  be  of  filiform  size. 

Diagnosis. — The  diagnosis  from  hernia  is  made  possible  by  the 
fact  that  in  the  latter  reposition  with  intestinal  gurgle  is  possible; 
whereas  a  hydrocele  cannot  be  reduced  unless  there  is  an  opening 
through  to  the  peritoneal  cavity.  On  gentle  percussion  a  hernia  will 
also  give  tympany.  Hernia  will  increase  in  size  as  a  result  of  cough- 
ing or  crying.  Congenital  hydrocele  may  disappear  spontaneously. 
Irregular  adhesions  in  the  canal  may  result  in  small  collections  of 
fluid  along  the  course  of  the  spermatic  cord,  thus  forming  hydrocele 
of  the  cord.  When  there  is  a  communication  of  the  peritoneum  with 
the  tunica  vaginalis,  a  large  hernia  may  result. 

The  diagnosis  of  hydrocele  of  the  cord  in  the  young  infant  is 
often  required  of  the  physician.  In  these  cases  we  find  a  collection 
of  fluid  around  the  cord  in  its  course  from  the  peritoneum  to  the 
testis.  This  fluid,  however,  does  not  communicate  with  the  cavity 
of  the  tunica  vaginalis  testis ;  nor  can  the  fluid  be  replaced,  as  the 
hernia  can,  into  the  abdominal  cavity.  The  fluctuating  swelling 
extends  from  the  testis  to  the  external  abdominal  ring. 

Treatment. — The  treatment  for  congenital  hydrocele  or  hydrocele 
of  the  cord  is  that  of  repeated  puncture  and  withdrawal  of  the  fluid. 
N"©  irritants  of  any  kind  should  be  used  in  congenital  forms  of 
hydrocele,  inasmuch  as  peritonitis  may  result  should  any  anomalous 
opening  into  the  peritoneal  cavity  exist. 

THE  CONGENITALLY  WEAK  (Premature  Infants). 

Infants  are  congenitally  weak  who  weigh  less  than  2000  grammes 
(41-  pounds),  have  a  body-length  of  42  centimetres,  and  who,  on 
account  of  a  lack  of  development  of  the  various  organs  and  a 
consequent  imperfect  performance  of  their  functions,  show  a  dimin- 
ished vital  energy.  Such  infants  may  be  premature,  weigh  as 
little  as  600  grammes  (1-|  pounds),  with  a  body-length  of  21  centi- 
metres, and  still  live.  As  a  rule,  however,  any  infant  weighing 
less  than  1000  grammes  (2.2  pounds)  cannot  live.  The  tem- 
perature must  also  be  considered  in  the  study  of  the  congenitally 
weak,  as  well  as  the  body-weight,  for  not  only  does  this  factor  influ- 
ence the  prognosis,  but  also  the  management  of  these  cases.  Con- 
genital weakness  may  thus  exist  to  various  degrees. 

Etiology. — Prematurity  is  a  most  frequent  cause  of  congenital 
weakness.  The  early  interruption  of  pregnancy  may  occur  in 
apparently  healthy  mothers   as   a   result   of  mechanical   influences, 


184  DISEASES  OF  THE  NEWBOBN. 

intercurrent  infectious  disease,  diseases  of  the  placenta  or  uterus,  or 
constitutional  disease.  Congenital  weakness  may  exist  in  one  of 
twins  or  triplets,  the  other  infants  being  born  strong  and  well  de- 
veloped. Though  most  frequently  found  among  premature  infants, 
congenital  weakness  may  exist  in  infants  born  at  full  term,  as  a 
result  of  the  debilitating  influence  of  tuberculosis  or  syphilis  in 
the  mother  on  the  development  of  the  foetus.  The  congenitally 
weak  are  also  found  among  infants  who  are  born  at  full  term,  but 
in  whom  there  has  been  for  some  reason  no  complete  expansion  of 
the  lungs  and  in  whom  atelectasis  results  (asphyxia  of  the  newborn). 
Thus,  congenital  weakness  may  at  times  go  hand  in  hand  with  pre- 
maturity ;  at  others  prematurity  is  not  an  essential  factor. 

Morbid  Anatomy. — Premature  infants  are  underweight  according 
to  the  degree  of  prematurity.  The  head  is  small  and  globular;  the 
pupils  still  show  the  pupillary  membrane ;  the  skin  is  red  and 
glistens ;  the  face  is  wrinkled ;  wool-hair  or  lanugo  covers  the  body ; 
nails  are  undeveloped ;  the  external  genital  organs,  the  clitoris  and 
nymphge,  are  prominent ;  the  brain  is  undeveloped ;  the  heart  and 
vessels  present  foetal  characteristics,  such  as  an  open  ductus  Botalli 
or  foramen  ovale;  the  thyroid  and  thymus  glands  and  the  supra- 
renal capsules  are  large ;  uric-acid  infarctions  are  found  in  the  kid- 
ney; the  intestinal  structures  and  bones  are  undeveloped. 

If  infection  occurs  the  lungs  show  areas  of  bronchopneumonia 
with  atelectasis ;  on  the  surface  of  the  lungs  there  are  hemorrhagic 
areas  resembling  infarctions.  In  other  words,  there  is  hemorrhagic 
pneumonia  due  to  infection  either  by  streptococci,  staphylococci, 
bacillus  coli  communis,  or  pneumococci.  The  bronchial  nodes  may 
be  enlarged  and  there  may  be  pericarditis.  The  intestines,  liver,  and 
kidney,  in  addition  to  being  undeveloped,  may  present  lesions  similar 
to  those  found  in  sepsis.  Infections  may  remain  local  and  limited  to 
the  point  of  entrance  of  the  bacteria,  or  may  become  general.  The 
portals  of  infection  are  solutions  of  continuity  in  the  skin,  mucous 
membrane  of  the  gastro-enteric  tract  and  respiratory  passages  which 
allow  the  entrance  of  bacteria  from  the  air,  garments,  or  objects 
brought  in  contact  with  the  infant's  hands,  linen,  or  food. 

Symptoms. — The  body  is  spare;  the  skin  is  soft  and  delicate,  uni- 
formly red  and  transparent,  showing  plainly  the  bloodvessels.  The 
delicacy  of  the  skin  renders  it  susceptible  to  traumatism,  resulting 
in  the  formation  of  erosions.  The  surface  is  cool,  pale,  icteric, 
sometimes  cyanotic.  Desquamation  of  the  skin,  present  normally 
in  the  newborn,  is  delayed  from  four  to  eight  weeks.  In  very 
severe  cases  there  may  be  sclerema. 

The  infant  does  not  cry,  but  rather  whimpers ;  the  respiratory 
movements  are  scarcely  noticeable,  there  is  muscular  inertia,   and 


TSE  CON GENIT ALLY  WEAK.  185 

the  infant  lies  in  a  torpid  condition.  The  intestine  and  stomach 
are  easily  disturbed;  the  liver  performs  its  function  imperfectly, 
and  in  many  of  these  cases  there  is  icterus.  A  temperature  as 
low  as  30°  C.  (86°  F.)  may  exist  and  continue  for  days.  These 
infants,  if  left  exposed  momentarily,  even  after  a  warm  bath, 
may  experience  a  serious  reduction  of  temperature.  They  are 
thus  easily  chilled,  and  attain  a  temperature  near  the  normal  only 
with  the  greatest  difficulty.  The  body-temperature  during  treatment 
in  the  incubator  may  not  rise  above  36.9°  C.  (98.4°  F.).  In  those 
infants  affected  with  sclerema  the  temperature  may  not  rise  for  days 
above  28°  to  35°  C.  (82.4°  to  95°  F.)  in  the  rectum.  As  a  direct 
result  of  the  low  body-temperature  and  disturbed  metabolic  proc- 
esses these  infants  suffer  from  cyanosis,  which  at  times  is  difficult 
to  dissipate. 

There  is  at  first  a  lack  of  nursing  power,  and  at  most  10  or  15 
c.c.  of  milk  are  taken  at  a  nursing.  The  evacuation  of  the  bowels 
takes  place  very  sluggishly,  often  days  apart ;  meconium  persists  in 
the  gut  as  long  as  six  to  eight  days.  The  urine  is  passed  in  much 
diminished  quantity,  and  the  loss  of  weight  is  more  rapid  than  is 
true  of  normal  infants. 

Should  a  premature  infant  develop  an  infectious  bronchopneu- 
monia, the  diagnosis  is  extremely  difficult.  Percussion  can  rarely 
establish  a  dulness  of  any  extent,  the  respiratory  movements  are 
feeble,  the  air  scarcely  enters  the  lungs,  cyanosis  is  present,  and  the 
temperature  may  be  subnormal.  The  infant  will  therefore  simply  fail 
in  a  general  way.  There  may  be  an  eruption  or  hemorrhages  in  the 
skin,  and  death  may  take  place  with  general  or  partial  convulsions. 

The  congenitally  weak  infant  may,  if  fed  incorrectly,  either  with 
too  much  or  faulty  food  (milk),  suffer  from  diarrhoea,  which  tends  not 
only  to  a  reduction  of  body-weight,  but  to  an  increase  of  weakness. 

Prognosis, — The  body-weight,  the  rectal  temperature,  and  the 
mode  of  feeding  determine  the  prognosis. 

Of  the  congenitally  weak  weighing  less  than  1200  grammes,  but 
few  or  none  are  saved;  of  those  weighing  1200  to  1400  grammes, 
40  per  cent,  are  saved;  of  those  weighing  1500  to  1599  grammes, 
86.7  per  cent,  are  saved;  and  from  2000  to  2500  grammes,  93.6 
per  cent,  are  saved  (Budin). 

As  an  exceptional  instance  of  successful  rearing  of  the  congeni- 
tally weak  may  be  mentioned  the  case  of  Villemin,  who  records  the 
saving  of  an  infant  who  at  birth  weighed  only  955  grammes  (2 
pounds). 

The  influence  which  the  rectal  temperature  has  on  the  prognosis 
is  shovTU  by  Budin,  who  found  that  of  cases  weighing  less  than  1500 
grammes,  with  a  rectal  temperature  of  32°  C.  or  less,  only  2  of  103 


186  DISEASES  OF  THE  NEWBORN. 

were  saved;  of  those  weighing  1500  to  2000  grammes,  with  a  rectal 
temperature  of  32^  C,  only  1  of  39  was  saved;  a  combined  mortality 
of  98  per  cent.  Therefore  the  rapid  reduction  of  temperature  is  an 
important  factor  in  the  mortality  of  these  infants. 

The  mode  of  feeding  is  an  important  element  in  the  prognosis, 
for  the  mortality  is  greater  among  the  congenitally  weak  or  prema- 
ture infants  brought  up  on  the  bottle  than  among  those  reared  on 
the  breast. 

It  is  interesting  to  note  the  observation  of  Budin,  that  of  54 
infants  who  had  at  departure  from  his  service  weighed  2800  to  3000 
grammes,  31  per  cent.  died.  Of  the  54  infants,  24  were  fed  arti- 
ficially, of  whom  41  per  cent,  died;  of  20  fed  at  the  breast,  only 
15  per  cent.  died. 

The  causes  of  death  among  the  congenitally  weak  are  principally 
infectious  bronchitis,  bronchoiDneumonia,  infectious  and  epidemic  dis- 
ease. Aside  from  infectious  diarrhoea,  syphilis  and  digestive  disor- 
ders play  an  important  role  as  causes  of  death. 

Management  of  Congenitally  Weak  Infants. — In  speaking  of 
the  management  of  congenitally  weak  infants  the  student  should  un- 
derstand that  each  country  has  its  favorite  method  of  managing  these 
cases.  If  a  premature  or  congenitally  weak  infant  is  born  asphyx- 
iated, the  treatment  is  much  the  same  at  the  start  as  that  detailed  in 
the  section  on  asphyxia  of  the  newborn ;  but,  as  intimated,  our  efforts 
must  be  directed  to  saving  the  congenitally  weak,  after  resuscitation 
methods  have  succeeded,  by  maintaining  the  body-temperature,  by 
feeding  the  infant  correctly,  and  by  supporting  the  heart  and  respira- 
tion. The  weight  and  the  rectal  temperature,  therefore,  not  the  age 
of  the  infant  at  birth,  will  decide  for  the  most  part  the  line  of  treat- 
ment, for  some  infants  at  full  term,  as  has  been  stated,  are  much 
below  the  normal  weight,  with  a  subnormal  temperature,  and  are 
therefore  congenitally  weak.  It  would  be  unsafe  to  outline  any 
treatment  based  only  on  the  age  of  the  infant  at  birth. 

We  will  first  take  up  the  methods  of  maintaining  the  body-tem- 
perature.    This  is  done  by  means  of  the  incubator. 

Incubators. — The  simplest  model  of  an  efficient  incubator  for 
maintaining  the  temperature  of  the  congenitally  weak  is  that  first 
introduced  by  Tarnier.  Though  many  complicated  pieces  of  appa- 
ratus have  been  constructed  since  the  time  of  this  clinician,  none  has 
surpassed  his  model  in  efficiency.  The  most  efficient  incubators  are 
made  of  metal  or  are  porcelain-lined,  simple  in  construction,  and 
allow  of  thorough  ventilation  while  maintaining  the  desired  degree 
of  temperature.  Infections  being  common  at  this  period,  an  incu- 
bator should  be  so  constructed  that  it  can  be  easily  cleaned  and 
subjected  to  sterilization  before  use.  Incubators  made  entirely  of 
wood  are  therefore  useless,  if  not  dangerous. 


TEE  CONGENITALLY  WEAK. 


187 


Of  the  elaborate  incubators  that  of  Lion  (Fig.  27)  has  given  the 
greatest  number  of  successes.  This  elaborate  apparatus  can  be  well 
ventilated  and  equably  heated.  The  heat  is  supplied  by  radiation. 
In  an  emergency,  any  kind  of  tin-lined  box  or  a  basket  padded  with 
cotton,  supplied  with  warming  bottles,  and  so  protected  on  top  as  not 
to  admit  of  a  too  rapid  escape  of  the  air,  answers  the  purpose  of  a 


Lion  incubator. 


more  elaborate  apparatus.  In  fact,  Chapin  has  shown  that  with 
very  elaborate  apparatus  he  has  had  less  brilliant  results  than  with 
simpler  means.  The  cause  of  his  ill-success  lies  in  the  fact  that 
complicated  apparatus  is  very  difficult  to  cleanse  after  having  once 
been  infected. 


188  DISEASES  OF  TEE  NEWBORN. 

The  indications  for  the  emploj-ment  of  any  form  of  incubator 
are:  (a)  Weight,  the  infant  weighing  2000  grammes  or  less.  Infants 
weighing  1800  grammes  if  vigorous,  may  be  reared  without  an  incu- 
bator. (&)  Subnormal  rectal  temperature,  as  has  been  emphasized 
elsewhere,     (c)  Cyanosis  or  sclerema. 

The  temperature  at  which  the  interior  of  the  incubator  should  be 
maintained  is  of  the  greatest  importance.  It  has  been  customary  to 
keep  the  temperature  of  the  interior  of  the  incubator  a  little  higher 
than  that  of  the  infant,  with  the  idea  that  in  this  way  the  heat 
which  is  transmitted  to  the  body  of  the  infant  is  necessary.  Later 
investigations  have  proved  that  an  infant  with  a  rectal  temperature 
of  30°-32°  C.  (86.6°  to  89.6°  F.)  will  be  more  comfortable  and 
thrive  better  in  an  incubator  kept  at  25°-26°  C.  (11°  to  78.8°  F.) 
than  in  one  in  which  the  temperature  is  35°-37°  C.  (95°  to  98.6° 
F.),  as  was  formerly  practised.  Therefore  the  interior  of  the  incu- 
bator should  have  a  temperature  of  25°  to  26°  C.  (77°  to  79°  F.). 

An  infant  brought  up  in  an  incubator  should  increase  regularly  in 
weight  and  strength.  It  should  have  one  or  two  movements  daily, 
and  should  take  its  nourishment  at  regular  intervals.  If  it  loses 
in  weight,  remains  cold,  cannot  be  roused,  breathes  superficially, 
develops  cyanosis,  dyspnoea,  diarrhoea,  cough,  or  vomiting,  the  outlook 
is  grave.  Even  should  the  infant  thrive,  it  must  not  be  allowed  to 
remain  torpid.  It  should  be  taken  out  of  the  incubator  cautiously, 
and,  if  the  respiratory  movements  are  shallow,  should  from  time  to 
time  be  caused  to  cry  by  mild  irritation.  In  this  way  the  lungs  are 
expanded  and  become  aerated.  The  infant  should  be  turned  on  its 
side  and  kept  lying  in  that  position,  thus  avoiding  hypostasis  in  the 
lower  or  posterior  part  of  the  lungs.  If  vomiting  occurs,  the  food 
should  be  modified,  peptonized,  or  reduced  in  quantity,  or  the  inter- 
vals of  feeding  lengthened.  Cyanosis,  as  has  been  mentioned,  is  met 
by  friction  and  flagellation.  In  carrying  this  out  caution  must  be 
observed  as  regards  the  liver,  which  is  quite  large  at  this  period  and 
easily  lacerated.  If  mucus  collects  in  the  throat,  it  must  be  cau- 
tiously aspirated  by  means  of  a  small  rubber  catheter  introduced  to 
the  back  of  the  pharynx,  passing  over  the  epiglottis  to  the  superior 
opening  of  the  larynx.  Success  in  feeding  will  also  aid  in  overcoming 
the  cyanosis. 

Feeding, — The  feeding  of  premature  infants  is  a  most  difficult 
problem.  At  this  time,  as  a  rule,  the  infant  is  unable  to. grasp  the 
breast.  Therefore  it  must  be  fed  with  a  pipette  or  a  nursing  tube 
constructed  for  this  purpose  (Fig.  28).  In  these  cases  the  milk  is 
pumped  from  the  breast  and  transferred  to  the  infant.  We  must  be 
careful  not  to  give  too  much  food,  for  thereby  diarrhoea  and  vomiting 
may  set  in;  on  the  other  hand,  too  little  food  will  only  tend  to  per- 


TRE  CONGENITALLY  WEAK. 


189 


Fig.  28. 


petiiate  the  weakness  and  cause  cyanosis.  During  the  first  ten  days 
there  may  be  loss  of  weight,  or  the  weight  may  remain  stationary  and 
finally  increase.  Budin  found  in  feeding  these  infants  that  there  were 
three  sets  of  cases,  in  each  of  which  he  could  estimate  the  amount  of 
food  taken  daily.  In  the  first  set  of  cases  the  infants  weighed  less 
than  1800  grammes  and  on  the  second  day  took  115  grammes 
of  nourishment;  on  the  tenth  day,  320  grammes.  The  second  set 
of  cases  were  those,  which  ranged  from  1800  to  2200  grammes, 
and  on  the  second  day  took  128  grammes  of  breast 
milk;  on  the  tenth  day,  410  grammes.  The  third  set 
of  cases  weighed  from  2200  to  2500  grammes,  and 
on  the  second  day  took  180  grammes  of  milk;  on  the 
tenth  day,  425  grammes.  Thus,  the  amount  of  food 
will  vary  with  the  weight  and  must  be  gradually 
increased  in  all  cases.  A  small  quantity  (see 
Infant-feeding)  must  be  given  at  each  feeding,  and 
the  feedings  should  be  at  intervals  of  one  and  a 
half  hours. 

Feeding  by  gavage  instead  of  by  the  pipette  was 
first  resorted  to  by  Tarnier.  It  may  be  said,  however, 
that  this  is  scarcely  necessary  except  in  very  torpid 
infants. 

We  must  be  exceedingly  careful  in  institutions, 
in  caring  for  premature  infants,  to  guard  against  the 
spread  of  any  form  of  disease  which  may  attack  them. 
A  bronchitis  in  a  premature  infant  is  a  more  serious 
disease  than  in  an  infant  born  at  full  term  with  nor- 
mal weight  and  temperature.  This  bronchitis  is  of  the 
infectious  type  and  very  fatal  to  premature  con- 
genitally  weak  infants.  As  a  rule,  it  leads  to  bron- 
chopneumonia and  in  institutions  is  apt  to  spread 
from  one  weakling  to  the  other.  Any  epidemic  dis- 
ease may  attack  these  infants ;  prophylaxis  therefore  plays  an  im- 
portant role  in  the  prognosis.  In  institutions  a  congenitally  weak 
infant  attacked  with  bronchitis  should  immediately  be  isolated  as  in 
any  other  infectious  disease.  In  private  practice  visitors  should  not 
be  allowed  to  see  these  congenitally  weak  infants  and  thus  infect 
them.  Anyone  suffering  Avith  an  ordinary  cold  should  be  forbidden 
to  come  in  the  vicinity  of  an  incubator. 

Bosi,  Giudi,  Escherich,  and  others  have  proposed  the  construction 
of  incubator  wards,  in  which  the  infant  should  not  be  exposed  to 
the  changes  of  temperature  and  danger  of  infection  when  taken  out 
of  its  crib.  It  may  be  stated,  however,  that  there  is  a  great  dis- 
advantage in  the  construction  of  incubator  wards,  for  neither  can 


Breck's  feeding 
tube  for  prema- 
ture infants. 


190  DISEASES  OF  THE  NEWBOBN. 

infections  be  avoided  any  more  than  in  ordinary  hospital  wards,  nor 
can  the  temperature  in  a  large  space  be  maintained  as  easily  as  in 
small  chambers ;  and,  finally,  the  isolation  of  one  little  patient  from 
another  cannot  be  as  complete  in  an  incubator  ward  as  in  the  indi- 
vidual crib  or  incubator. 

Bath  and  Clothing  of  the  Congenitally  Weak.^ — The  congenitally 
weak  or  premature  infant  is  easily  chilled,  and  therefore  after  birth 
should  not  be  bathed.  It  should  be  well  anointed  with  oil,  and  this 
removed  with  absorbent  cotton  in  such  a  manner  that  the  body  is  left 
clean  and  free  from  vernix  caseosa  or  extraneous  substances.  The 
infant  is  then  wrapped  in  one  layer  of  sterilized  cotton  covering  the 
trunk  and  the  extremities.  Over  this  is  sewed  a  jacket  of  sterile  gauze 
so  as  to  encase  the  whole  body.  The  buttocks  and  genitals,  however, 
are  left  free,  so  that  any  meconium  or  urine  that  is  passed  may  be 
caught  by  cotton  placed  against  these  parts.  In  this  way  the  infant 
is  not  chilled  when  taken  from  the  incubator  to  be  fed  or  washed. 

Ultimate  Fate  of  the  Incubator  Infant.— Some  of  the  best  de- 
veloped men  and  women  came  into  the  world  congenitally  weak,  so 
that  the  physician  should  spare  no  effort  to  bring  about  success,  no 
matter  how  weak  the  infant  may  appear  at  the  outset.  Especially 
encouraging  are  the  results  obtained  with  the  congenitally  weak  when 
it  has  been  possible  to  feed  the  infant  from  the  beginning  to  the  termi- 
nation of  infancy  with  breast  milk.  The  statistics  of  Budin,  quoted 
elsewhere,  show  conclusively  that  of  the  premature  infants  discharged 
from  his  institution  with  a  weight  of  2800  to  3000  grammes,  those 
who  fared  best  were  the  breast-fed  infants,  of  whom  only  15  per  cent, 
died  before  attaining  maturity,  whereas  41  per  cent,  of  the  bottle-fed 
infants  died  during  infancy. 

The  physician  will  have  an  easier  task,  if,  in  addition  to  the  incu- 
bator, he  makes  every  effort  to  obtain  human  milk  for  the  weakling. 

Feeding  of  the  Congenitally  Weak  and  Premature  Infants. — 
Breast-feeding. — The  ideal  method  of  feeding  the  congenitally  weak, 
and  the  one  which  is  attended  with  the  greatest  number  of  successes, 
is  that  with  breast  milk.  There  are,  however,  some  facts  which  must 
not  be  lost  sight  of  in  feeding  the  congenitally  weak  on  the  breast. 
Their  suction  power  is  much  below  that  of  the  normal  infant  born  at 
full  term.  In  some  cases  the  congenitally  weak  infant  is  unable  to 
nurse  at  all.  If  the  mother  and  not  a  wet-nurse  is  to  nourish  the 
infant,  the  milk  must  be  pumped  from  the  breast  and  fed  to  the  child 
by  means  of  the  Breck  Feeder,  if  the  infant  is  unable  to  nurse  the 
breast  directly.  In  extreme  cases  the  infant  will  not  even  have  the 
power  to  swallow  the  milk  pumped  from  the  breast  and  fed  to  it  with 
a  feeder.  Under  such  circumstances  the  milk  must  be  carefully  fed 
to  the  infant,  by  means  of  gavage,  four  or  five  times  in  the  twenty- 


TRE  CONGENITALLY  WEAK.  191 

four  hours.  As  a  rule,  however,  the  mother  of  a  premature  infant 
will,  if  the  infant  is  born  much  before  full  term,  have  very  little  milk 
in  her  breast.  In  such  a  case,  it  is  advisable  to  obtain  a  wet-nurse 
whose  milk  is  uniform,  and  whose  child  is  at  least  one  or  two  months 
of  age.  Should  a  wet-nurse  not  be  available  at  this  time,  the  infant 
may  be  placed  on  modified  milk  until  the  milk  appears  in  the  mother's 
breast.  A  wet-nurse  who  nurses  a  congenitally  weak  infant  exclu- 
sively will  lose  her  milk  gradually,  because  the  congenitally  weak  in- 
fant, though  it  nurses  the  breast,  exerts  so  little  suction  power  that  the 
normal  excitation  to  continued  glandular  activity  of  the  breast  is  lack- 
ing and  the  milk  gradually  diminishes  in  quantity,  finally  ceasing  to 
be  secreted.  It  is  well,  therefore,  to  allow  the  wet-nurse  to  nurse  her 
own  infant  while  supplying  the  excess  of  milk  to  the  congenitally 
weak  infant  she  is  caring  for.  Under  this  arrangement  there  need 
be  no  fear  that  either  infant  will  suffer  from  an  insufiiciency  of  milk, 
inasmuch  as  the  additional  stimulus  given  by  the  two  infants  to  the 
gland  will  result  in  an  increased  secretion  of  milk,  a  fact  which  has 
been  repeatedly  proved. 

The  amount  of  breast  milk  which  a  congenitally  weak  or  pre- 
mature infant  will  take  from  the  breast  will  vary  widely  with  the 
strength,  age,  and  weight  of  the  infant.  As  a  rule,  the  amount  will 
vary  from  200  to  500  c.c.  daily.  The  nursings  should  be  at  intervals 
of  an  hour  to  an  hour  and  a  half.  The  younger  the  infant  the  more 
frequent  should  be  nursings  and  the  smaller  the  quantity  at  each 
feeding.  If  the  infant  is  unable  to  nurse  the  breast,  the  milk  may 
be  pumped  off  and  given  in  a  bottle  or  feeder  to  the  infant;  or  i's 
given,  as  has  been  stated,  by  gavage.  It  may  happen,  as  has  been 
intimated,  that  the  mother,  after  the  birth  of  a  premature  infant,  has 
very  little  milk  in  her  breast.  If  such  an  infant  is  placed  tempor- 
arily on  modified  milk,  the  milk  may  appear  in  the  mother's  breast 
after  a  week  or  two,  and  the  gland  may  be  excited  to  increased  secre- 
tion by  placing  the  infant  at  the  breast,  especially  if  it  be  not  too 
premature  or  weak. 

Artificial  Feeding. — The  feeding  of  the  congenitally  weak  or  pre- 
mature infant  with  modified  milk  is  a  very  difiicult  task,  inasmuch 
as  comparatively  few  facts  are  at  our  disposal  to-day  as  to  the  success 
of  this  mode  of  feeding.  We  know  that  the  success  attending  the 
feeding  of  the  congenitally  weak  or  premature  infant  on  cows'  milk 
is  even  less  than  that  of  feeding  the  normal  newborn  infant.  We 
will  illustrate  the  feeding  of  these  infants  by  taking  as  an  example 
a  premature  or  congenitally  weak  infant  born  at  seven  and  a  half 
months  of  pregnancy.  Such  an  infant  is  first  placed  upon  a  mixture 
containing  1  per  cent,  of  fat,  0.25  per  cent,  of  proteids,  and  5  or  6 
per  cent,  of  sugar.     The  infant  is  given  10  c.c,  or  2-J-  drachms,  at 


192  DISEASES  OF  THE  NEWBOBN. 

each  feeding,  the  intervals  between  the  feedings  being  one  hour. 
Twelve  feedings  are  given  in  the  twenty-four  hours,  rest  being  given 
for  the  remaining  twelve  hours. 

After  a  week  of  extra-uterine  life  the  percentage  of  proteids  is 
doubled,  the  fat  and  sugar  remaining  the  same.  From  the  fifteenth 
day  of  life  the  infant  Avill  be  taking  -J  ounce  at  each  feeding,  twelve 
feedings  being  given  in  the  twenty-four  hours.  After  the  fifteenth 
day  the  proteids  may  be  increased,  so  that  from  the  thirtieth  day  of 
life  the  infant  will  be  taking  a  mixture  of  1  to  1.5  per  cent,  of  fat, 
0.75  per  cent,  of  proteids,  and  6  per  cent,  of  sugar,  1^  ounces  at  each 
feeding,  with  intervals  of  two  hours  between  the  feedings.  Ten  or 
twelve  feedings  are  given  in  the  twenty-four  hours.  At  this  time  the 
infant  will  have  approached  the  age  of  a  full-term  infant.  We  should 
now  be  cautious  not  to  increase  the  percentages  or  strength  of  the 
mixture  too  rapidly,  but  rather  to  let  them  remain  stationary  and 
watch  the  increase  of  weight.  If  the  weight  increases  along  physio- 
logical lines,  we  are  then  guided  by  the  same  considerations  which 
would  obtain  with  an  infant  born  at  full  term. 

Congenitally  weak  infants,  fed  upon  modified  milk  mixtures,  who 
show  dyspeptic  disturbances,  evidenced  by  green  stools  or  white  curds 
in  the  movements,  should  a  wet-nurse  be  unavailable,  are  fed  with  a 
peptonized  mixture.  The  peptonizing  is  carried  out  with  good  results 
by  the  process  detailed  elsewhere. 

Mixed  Feeding. — This  is  a  combination  of  breast  and  bottle-feeding 
in  those  cases  in  which  the  breast  does  not  yield  sufficient  milk  and 
the  weight  of  the  infant  remains  stationary.  This  is  seen  in  cases 
of  twins  nursed  by  the  mother  or  even  by  a  wet-nurse.  In  such  cases 
several  feedings  by  means  of  the  bottle  may  be  given  daily  in  addition 
to  the  breast. 

The  Amount  of  Food  Taken  by  the  Congenitally  Weak  Infant 
Daily. — It  has  been  sho'wn  conclusively  that  the  congenitally  weak 
infant  at  the  breast  will  consume  daily  approximately  one-fifth  of  its 
own  weight  of  breast  milk.  The  so-called  normal  quantities  of  breast 
milk  taken  by  the  congenitally  weak  infants,  carefully  weighed  before 
and  after  nursing,  are  found  by  Budin  to  be  as  follows: 

Infants  of  1000  grammes,  200  grammes. 


1500 

250    " 

"      1800 

360    " 

2000 

400    " 

2500 

500    " 

"      3000 

600    " 

The  amount  of  breast  milk  taken  daily  in  the  first  ten  days  of 
life  gradual!}^  increase,  as  stated,  from  115  grammes,  taken  the  second 
day  by  an  infant  of  1800  grammes,  to  320  grammes  on  the  tenth 


ASFHYXIA    OF   THE  NEWBORN  INFANT.  193 

day.  An  infant  weighing  2200  to  2500  grammes  will  take  on  the 
average  180  grammes,  taken  the  second  day,  to  425  on  the  tenth  day, 
its  normal  quantity  of  food. 

These  quantities  of  breast  milk  consumed  by  the  congenitally 
weak  will  be  seen  to  exceed  or  equal  in  amount  what  the  normal 
infant  at  full  term  consumes.  This  proves  distinctly  what  has 
always  been  insisted  upon  by  the  writer  that  the  amount  of  food 
necessary  to  the  infant  is  determined  by  the  needs  of  the  body  and 
not  by  any  arbitrary  standard  of  stomach  capacity.  In  other  words, 
the  congenitally  weak  infant,  though  under  weight,  really  needs  more 
calories  of  foodstuffs  per  kilogramme  of  body-weight  than  the  full- 
term  infant,  because  it  uses  up  more  heat  units  of  energy,  having 
more  extent  of  body  surface  exposed  for  its  weight  than  the  normal 
full-term  infant.  Unless  the  calories,  in  the  form  of  increased  nour- 
ishment, are  supplied  to  these  congenitally  weak  and  premature 
infants,  they  fail  to  thrive,  become  cyanotic,  and  die.  Thus,  when 
feeding  these  infants  with  cows'  milk,  modified  or  peptonized,  it  must 
not  be  forgotten  that  the  above  principles  hold  true,  and  that  the 
amount  of  breast  milk  consumed  by  the  congenitally  weak  is  a  better 
guide  as  to  the  necessary  quantity  of  artificial  food  to  be  given  these 
infants  than  the  weight  or  stomach  capacity.  On  the  other  hand,  if 
the  congenitally  weak  are  fed  in  excess  of  their  needs,  there  result 
vomiting  and  diarrhoea,  with  loss  of  weight  or  stationary  weight. 

ASPHYXIA    OF    THE    NEWBORN    INFANT. 

Definition  and  Etiology. — Asphyxia  is  a  condition  produced  by  an 
interference  with  the  oxygenation  of  the  blood.  In  the  uterus  respi- 
ration is  effected  through  the  placenta.  If  the  placenta  is  separated 
wholly  or  in  part  from  its  uterine  attachment,  or  the  circulation  in 
this  organ  is  interfered  with,  the  disturbance  of  the  normal  conditions 
causes  efforts  at  respiration,  the  result  of  deficient  oxygenation  of  the 
blood.  Asphyxia  may  thus  be  produced  by  tonic  contraction  of  the 
uterus,  premature  rupture  of  the  membranes  and  escape  of  the  liquor 
amnii,  asphyxiation  of  the  mother,  a  hemorrhage,  the  administration 
of  drugs  to  the  mother  intra-partum,  pressure  on  the  cord,  injury  to 
the  head  intra-partum,  or  through  pressure  on  the  vagus  intra-partum, 
with  disturbance  of  the  respiratory  centres.  If  the  placenta  is  sepa- 
rated prematurely  there  are  consequent  efforts  at  respiration,  during 
which  liquor  amnii  or  mucus  may  be  aspirated  and  asphyxia  thus 
produced.  In  the  extra-uterine  form  of  asphyxiation  the  infant  is 
born  and  makes  efforts  at  respiration;  but  inherent  constitutional 
weakness,  weakness  of  the  respiratory  muscles,  deformity  of  the  chest, 
or  disease  of  the  lungs  renders  full  expansion  of  the  lungs  impossible. 

13 


194  DISEASES  OF  TEE  NEWBORN. 

Syphilitic  disease  of  the  lungs,  tumors  of  the  lungs,  or  affections  of 
the  pleura  may  have  the  same  effect. 

Morbid  Anatomy. — The  blood  in  infants  who  have  died  asphyxi- 
ated is  thin  and  fluid.  The  right  heart  and  large  vessels  are  filled 
with  blood,  as  are  also  the  sinuses  of  the  dura  mater,  pia  mater,  and 
liver.  The  liver  is  dark  and  bluish  in  tint.  Punctate  hemorrhages 
are  found  in  the  pia  mater,  pleura,  pericardium,  peritoneum,  liver, 
kidney,  retroperitoneal  connective  tissue,  uterus,  kidneys,  suprarenal 
capsule,  and  retina.  There  is  a  serosanguinolent  effusion  into  the 
cavity  of  the  peritoneum,  pleura,  and  pericardium.  CEdema  of  the 
extremities,  scrotum,  and  connective  tissue  about  the  umbilical  ves- 
sels and  pia  mater  is  present.  The  lungs  are  dark  red  and  heavy. 
Ecchymoses  are  seen  underneath  the  pleura  and  pericardium.  In 
the  lungs  there  are  islands  of  aerated  tissue  and  areas  of  atelectasis, 
even  though  the  infant  has  breathed.  The  trachea  and  bronchi  may 
be  filled  with  liquor  amiiii,  mucus,  or  meconium;  the  latter  is  rec- 
ognized by  the  presence  of  lanugo,  epithelial  scales,  fatty  crystals, 
bilirubin,  and  cholesterin  crystals.  The  stomach  may  be  filled  with 
air  or  meconium. 

Symptoms. ^ — If  in  a  normal  state  when  born,  the  infant  breathes 
energetically,  cries  lustily,  and  opens  its  eyes,  and  the  skin,  which  is 
of  a  purple  hue  at  first,  rapidly  assumes  a  pinkish  tint.  If  asphyxia 
be  present,  however,  we  may  have  two  sets  of  symptoms,  which  are 
characteristic  of  two  forms  of  this  condition. 

In  the  first  form,  or  early  stage,  of  asphyxia,  the  skin  has  a 
bluish  or  pinkish-blue  tint.  The  face  is  swollen  and  the  conjunctivae 
injected.  The  infant  does  not  move  the  extremities.  The  muscu- 
lature retains  its  tonicity;  the  heart  action  is  slow  but  forcible;  the 
apex  beat  is  apparent  to  the  eye;  the  vessels  of  the  cord  are  filled 
with  blood  and  pulsate;  the  respiratory  efforts  may  be  shallow  and 
infrequent,  or  absent ;  the  infant  can  be  roused  and  caused  to  cry. 

In  the  more  advanced  form  of  asphyxia  the  face  is  pale  and  waxy, 
the  lips  are  cyanosed;  the  extremities  hang  lax,  and  the  muscular 
tonus  is  absent;  the  head  falls  to  one  side  and  the  jaw  drops.  There 
is  no  attempt  at  respiration  or  only  imperfect  gasping  efforts.  The 
infant  has  a  corpse-like  appearance.  The  heart-beat  is  weak  though 
palpable.  The  vessels  of  the  cord  are  collapsed  and  pulsation  is 
weak.  If  a  few  gasps  of  respiration  are  made  at  birth,  these  soon 
cease.  On  attempt  at  respiration  the  ribs  are  retracted,  but  the 
muscles  of  the  face  are  immobile.  Air  is  prevented  from  entering 
the  lung  by  the  inspired  mucus.  The  reflexes  are  absent.  If  un- 
treated, infants  in  this  stage  of  asphyxia  die.  If  they  live,  efforts 
at  respiration  must  be  repeatedly  encouraged,  else  the  infants  relapse 
into  a  torpid  condition  and  the  respirations  become  superficial. 


ASPHYXIA    OF   THE  NEWBOBN  INFANT.  195 

Diagnosis. — Asphyxia  must  be  differentiated  from  the  effects  of 
pressure  due  to  cerebral  hemorrhage  occurring  at  birth  during  a  pro- 
longed labor  or  application  of  the  forceps.  In  a  large  hemorrhage 
death  is  rapid,  but  in  slight  hemorrhage  it  may  be  difficult  to  make 
a  differential  diagnosis.  If  there  is  a  hemorrhage  on  the  surface  of 
the  brain,  the  symptoms  may  closely  resemble  those  of  asphyxia. 
The  breathing  is  very  superficial;  the  infant  lapses  into  sopor;  the 
pulse  may  at  first  be  slow  and  subsequently  rapid.  There  may  be 
occasional  convulsions.  The  fontanelle  in  cases  of  hemorrhage  on 
the  surface  of  the  brain  has  a  peculiar  hard  feel.  The  subsequent 
history  only  will  clear  up  these  cases.  Asphyxia  may  be  combined 
with  cerebral  hemorrhage.  The  history  of  the  birth  as  to  the  use  of 
forceps  and  the  duration  of  the  labor  will  aid  us.  If  after  irritation 
the  infant  relapses  into  sopor,  if  the  pulse  continues  slow  and  there 
are  repeated  convulsions,  we  may  assume  the  existence  of  hemorrhage. 

Prognosis. — The  prognosis  in  all  forms  of  asphyxia,  if  untreated, 
is  grave,  and  in  the  second  stage  is  necessarily  fatal.  If  treated, 
however,  the  majority  of  these  cases  recover,  especially  in  the  first 
stage.  As  to  the  cases  of  the  second  stage,  much  will  depend  on  the 
duration  of  the  second  stage  of  labor  and  the  compression  of  the  cord. 
The  cases  in  which  cerebral  hemorrhage  of  any  severity  is  combined 
with  the  asphyxia  are  grave.  Little  and  Mitchell  have  demonstrated 
that  idiocy  may  subsequently  develop  in  these  cases. 

Treatment. — The  treatment  of  asphyxia  is  directed  to  clearing  the 
air-passages  as  much  as  possible  of  obstructing  mucus,  increasing  the 
number  of  respirations,  and  stimulating  the  circulation.  The  mucus 
and  aspirated  meconium  are  quickly  but  gently  removed  from  the 
mouth  by  the  finger. 

An  instrument  has  been  devised  for  the  aspiration  of  mucus  from 
the  upper  part  of  the  larynx  and  trachea ;  but  this  instrument  is  not 
always  at  hand,  and  a  sterilized  catheter,  ISTo.  7  French,  can  be  easily 
introduced  to  the  rima  glottidis,  and  the  mucus  thus  aspirated  by 
means  of  mouth  suction.  Care,  of  course,  must  be  taken  by  the 
njirse  or  physician  not  to  infect  the  catheter.  To  avoid  this  a  small 
piece  of  glass  tubing  may  be  attached  to  the  distal  end,  and  in  the 
lumen  of  the  tubing  a  small  piece  of  cotton  may  be  loosely  plugged; 
thus  saliva  and  bacteria  from  the  mouth  will  not  enter  the  catheter. 
Introduction  of  the  catheter  into  the  trachea  is  hardly  necessary. 

In  order  to  stimulate  the  surface,  the  infant  is  quickly  placed  in 
a  bath  at  40.5°  C.  (105°  F.),  and  then  in  a  cold  bath,  thence  trans- 
ferred to  a  warm  blanket  and  rubbed  thoroughly  dry.  After  this 
the  infant  is,  if  possible,  roused  by  striking  the  buttocks  quite  sharply. 
If  these  methods  do  not  cause  the  infant  to  cry  and  breathe  deeply, 
artificial  respiration  by  the  Schultze  method  should  be  resorted  to. 


196  DISEASES  OF  THE  NEWBOBN. 

The  operator,  standing  with  his  body  well  balanced,  grasps  the  infant 
by  the  shonlders,  the  thnmbs  being  on  the  anterior  aspect  of  the 
thorax,  the  index  fingers  in  the  axilla?,  and  the  other  fingers  on  the 
back  of  the  chest.  The  head  is  supported  by  the  ulnar  side  of  the 
wrists.  The  operator  allows  the  infant  to  hang  down  from  his  hands 
between  his  legs.  The  infant  is  then  raised  or  swung  upward  above 
the  level  of  the  operator's  head  to  the  vertical,  so  that  the  lower  part 
of  the  trunk  of  the  infant  is  bent  on  the  thorax.  The  thorax  is  thus 
compressed,  causing  passive  expiration.  The  infant  is  held  for  an 
instant  in  this  position,  and  then  swung  down  to  the  original  hanging 
position.     Passive  inspiration  is  thus  performed. 

The  Schultze  manoeuvre  should  be  repeated  at  the  rate  of  about 
ten  times  a  minute,  at  intervals  of  several  seconds.  Care  must  be 
exercised  not  to  injure  the  thorax  by  pressure  of  the  thumbs  or  the 
other  fingers,  the  infant  being  swung  on  the  index  fingers.  After 
applying  the  Schultze  method  as  above  for  a  few  minutes  the  infant 
is  given  a  warm  bath,  and,  if  respiration  is  not  completely  established, 
the  swingings  are  repeated.  By  this  method  the  bronchi  and  mouth 
are  freed  from  mucus,  meconium,  and  liquor  amnii,  if  present.  The 
Laborde  method  is  that  by  which  traction  is  made  on  the  tongue  ten 
or  twelve  times  a  minute.  The  infant  is  laid  on  a  flat  surface  with  a 
folded  towel  placed  between  the  shoulders,  and  the  tongue  is  rhyth- 
mically drawn  forward  by  means  of  a  forceps  and  allowed  to  recede  a 
number  of  times,  corresponding  to  the  normal  number  of  respirations. 

The  mouth-to-m,outh  method  consists  in  first  clearing  the  upper 
air-passages  of  mucus.  The  operator  then  forcibly  blows  into  the 
mouth  of  the  infant.  The  chest  of  the  infant  is  then  compressed 
to  force  out  the  air  (expiration  of  the  infant).  This  procedui"e  is 
repeated  as  often  as  sixteen  times  a  minute. 

The  Dew  method  seeks  to  accomplish  the  same  result  as  the 
Schultze  method,  but  by  simpler  means.  The  infant  is  grasped  by 
the  one  hand  at  the  nape  of  the  neck,  and  by  the  other  hand  at  the 
knees.  The  thighs  rest  in  the  palm  of  the  hand.  The  thorax  is 
flexed  on  the  abdomen,  and  then  extension  is  performed.  Alternate 
expiration  and  inspiration  take  place.  Inflation  of  the  lungs  by 
means  of  instruments  introduced  into  the  larynx  is  dangerous.  There 
are  other  methods  of  artificial  respiration  which  may  be  resorted  to, 
such  as  the  Marshall-Hall  method,  but,  on  the  whole,  the  Schultze 
procedure  seems  the  most  effective. 

The  danger  in  all  cases  is  in  abandoning  efforts  at  resuscitation 
too  early.  We  should  persist  in  our  efforts  as  long  as  the  heart 
action  continues.  After  the  infant  has  been  brought  out  of  the  stage 
of  severe  asphyxia  there  is  always  danger  of  relapse  into  a  soporous 
state.  In  this  condition  flagellation  on  the  buttocks  at  regular  inter- 
vals may  be  necessary  for  days. 


ASPHYXIA  SUBSEQUENT  TO  BIBTH.  197 

In  some  cases,  even  after  resuscitation  has  taken  place,  mucus 
will  continue  to  collect  in  the  upper  air-passages.  In  other  words,  on 
account  of  cardiac  weakness  there  is  a  persistent  pulmonary  oedema. 
In  such  cases  tracheal  mucus  will  collect  in  the  upper  part  of  the 
glottis,  and  I  have  seen  brilliant  results  follow  the  occasional  intro- 
duction into  the  upper  part  of  the  glottis  of  the  catheter  for  the 
removal  of  this  mucus  by  means  of  suction.  I  have  made  use  of  this 
procedure  at  very  short  intervals  throughout  the  twenty-four  hours 
with  excellent  results. 

In  cases  of  asphyxia  the  after-treatment  is  as  important  as  the 
immediate  measures.  The  infant  must  be  constantly  watched.  If 
the  respirations  become  too  shallow,  the  infant  is  gently  flagellated ; 
and  when  mucus  collects  in  the  throat,  it  is  removed. 

One  of  the  best  drugs  to  help  us  with  these  weakly  infants  is  the 
ammonium  carbonate  (^  gTain)  given  every  two  hours,  with  or  with- 
out strychnia  sulphate  (^ooth  of  a  grain  every  three  hours).  The 
infant  must  be  kept  warm  and  carefully  fed.  Some  of  these  infants 
will  not  nurse,  either  on  account  of  inherent  weakness  or  paralysis 
of  the  tongue,  caused  by  pressure  of  the  forceps,  and  much  patience 
must  be  exercised.  If  the  tongue  has  been  injured  or  the  hypo- 
glossal nerve  pressed  upon  during  birth,  one  side  of  the  tongue  may 
be  deflected,  and  at  each  feeding  the  food  may  find  its  way  into  the 
upper  part  of  the  glottis,  causing  spasms  of  coughing  and  cyanosis. 
In  these  cases  the  nurse  will  discover  that  the  infant  can  be  fed  in  a 
certain  posture  more  successfully  than  in  another,  or  with  a  pipette 
instead  of  the  nursing  bottle.  If  the  cyanotic  attacks  are  frequent 
oxygen  must  be  given  almost  continuously  for  hours.  After  being 
worked  over  for  days,  such  infants  may  make  a  good  recovery  or 
die  and  show  extensive  atelectasis  in  spite  of  the  fact  that  respiration 
has  occurred. 

ASPHYXIA    SUBSEQUENT    TO    BIRTH. 

In  these  cases  there  is  no  disturbance  of  the  placental  circulation 
previous  to  the  birth  of  the  infant,  and  therefore  no  asphyxia. 
Asphyxia  appears  after  birth  as  a  result  of  some  abnormality  in 
the  respiratory  apparatus  or  of  disease  of  the  lung,  such  as  syphilitic 
hepatization ;  of  pleural  exudate ;  of  compression  of  the  air-passages 
by  a  struma ;  or  of  defects  of  the  diaphragm  or  deficient  development 
of  the  lungs.  In  some  cases  there  may  have  been  injury  or  compres- 
sion in  the  vicinity  of  the  respiratory  centre. 

Prematurity  carries  with  it  a  pliable  condition  of  the  ribs  and 
weakness  of  the  respiratory  muscles,  an  insufiicient  development  of 
the  respiratory  centre,  and  foetal  atelectasis,  which  give  rise  to  a  state 


1  98  DISEASES  OF  THE  NEWBOBN. 

of  asphyxia.  The  more  premature  the  infant  the  more  pronounced 
are  these  conditions. 

Symptoms. — The  infant  makes  no  decided  eifort  at  respiration 
after  birth.  Inspiration  is  absent  or  is  hardly  noticeable  and  shal- 
low. Rales  are  absent.  The  vessels  in  the  umbilical  cord  are  filled 
with  blood  and  pulsate  distinctly.  The  heart  has  a  normal  frequency 
at  first;  then  the  contractions  become  slower  and  may  eventually  be 
increased  in  frequency.  The  skin  is  bluish-red  in  color ;  the  extrem- 
ities are  cool.  If  there  is  any  disease  or  deformity  of  the  lung,  the 
infant  dies  soon-  after  birth.  These  cases  are  only  of  scientific 
interest.  Of  more  importance  to  the  physician  is  the  premature 
infalit  normal  in  all  respects  save  in  the  fact  of  its  expulsion  from 
the  uterus  before  term. 

Premature  infants  at  the  sixth,  seventh,  or  eighth  month  are  not 
all  born  debilitated,  nor  are  all  debilitated  infants  necessarily  prema- 
ture. There  are  infants  born  at  the  eighth  month  which  are  as  easily 
reared  as  at  full  term.      (See  The  Congenitally  Weak.) 

ATELECTASIS   OF   THE   LUNGS. 

This  condition  has  been  referred  to  in  the  section  on  Asphyxia. 
Atelectasis,  or  collapse  of  the  lung,  may  be  congenital  or  acquired. 
In  the  congenital  variety  the  infant  is  either  weakly  or  born  prema- 
turely. The  respiratory  muscles  do  not  possess  sufficient  tonus  to 
inflate  the  lung.  The  result  is  that  the  lung  remains  in  the  collapsed 
foetal  state.  In  the  acquired  form  the  lung  cannot  expand,  as  a  result 
of  obstructions  of  the  bronchi  or  alveoli,  compression  of  the  lung  by 
an  exudate  in  the  pleura,  deformity  of  the  vertebral  column,  or 
aneurysm  of  the  aorta. 

Etiology. — The  lung  at  birth  is  compact,  the  alveoli  being  col- 
lapsed. The  respiratory  efforts  inflate  the  alveoli,  and  the  lung- 
unfolds  gradually,  as  described  elsewhere.  If  after  birth  the  respira- 
tory efforts  are  insufficient  and  the  bronchi  obstructed,  or  parts  of  the 
lung  compressed  or  uninflatable,  then  a  greater  or  less  number  of  the 
lobuli  remain  uninflated  and  atelectasis  results. 

If  part  of  the  lung  which  is  functionating  is  thrown  out  of  action 
from  any  cause,  an  acquired  atelectasis  results.  This  may  result 
either  from  compression  (compression  atelectasis)  or  from  obstruc- 
tion (obstructive  atelectasis).  A  bronchus  may  be  closed  or  the 
alveoli  may  be  filled  with  fluid  masses.  Atelectasis  may  result  from 
an  accumulation  of  fluid  or  air  in  the  pleura,  or  from  an  inability 
of  the  diaphragm  to  act  in  consequence  of  curvature  of  the  spine, 
aortic  aneurysm,  or  contracture  of  the  pleura  with  thickening. 

If  the  whole  lung  is  involved,  it  is  pressed  against  the  spine,  con- 


ATELECTASIS  OF  TEE  LUNGS.  199 

densed  and  tough,  devoid  of  air,  of  a  pale-red  color  or  pigmented. 
The  areas  of  partial  atelectasis  have  the  same  characteristics,  but  are 
redder  and  filled  with  blood.  If  a  bronchus  or  bronchiole  is  ob- 
structed, the  lung  collapses  and  returns  to  the  foetal  state.  It  becomes 
the  seat  of  passive  congestion,  so  that  the  atelectatic  area  is  bluish-red 
in  color.  Obstructive  atelectasis  is  quite  frequent,  and  is  seen  accom- 
panying any  inflammatory  process  of  the  swollen  bronchi.  The 
bluish-red  atelectatic  areas  are  seen  on  the  surface  of  the  lung  to 
alternate  with  the  red  areas  containing  air.  Congenital  atelectasis 
reveals  portions  of  the  lung  as  firm,  non-crepitant,  dark-blue,  de- 
pressed areas  with  a  smooth  surface  on  section.  These  areas  can  be 
inflated,  and  then  cannot  be  distinguished  from  the  surrounding  lung. 
Inflammatory  atelectasis  shows  the  same  appearance.  At  autopsies 
on  children  dying  of  inflammatory  disease  of  the  lung,  these  areas  of 
atelectasis  are  seen  more  frequently  the  younger  the  subject.  Eachitic 
children  are  especially  subject  to  atelectasis,  on  account  of  their 
inability  to  inflate  the  lung  completely. 

Symptoms. — The  symptoms  of  atelectasis  are  not  always  clearly 
defined.  As  a  rule,  the  infants,  if  premature,  are  weak ;  their  torpid 
state  has  been  described  in  the  section  on  the  Congenitally  Weak. 
On  the  other  hand,  should  atelectasis  develop  some  time  after  birth 
as  a  result  of  inflammation  and  plugging  of  the  smaller  bronchi,  we 
shall  have  the  combined  physical  sign  of  atelectasis,  bronchitis,  and 
possibly  bronchopneumonia.  In  this  class  of  cases  the  physical  signs 
are  as  follows : 

Inspection. — There  is  intense  dyspnoea ;  the  lower  ribs  are  re- 
tracted, and  the  efforts  at  inspiration  are  labored  and  move  the  upper 
part  of  the  thorax  less  than  the  lower  portion.  The  surface  is  pale 
and  sometimes  cyanosed.  Efforts  at  coughing  are  ineffectual,  but 
may  bring  up  a  frothy,  clear  expectoration  which  adheres  to  the  lips. 
Sometimes  the  breathing  is  quite  irregular  and  catchy,  or  very  shal- 
low ;  at  times  the  infant  seems  to  cease  breathing. 

Palpatio7i. — Palpation  is  negative  except  where  rales  are  abun- 
dant, when  a  fine  rhonchal  fremitus  is  present.  There  is  little  or  no 
vocal  fremitus ;  it  may  be  increased  or  it  may  be  diminished,  espe- 
cially in  areas  designated  vesiculo-tympanitic. 

Percussion.- — Percussion  reveals  distinct  small  areas  of  dulness 
with  a  tympanitic  note,  slight  dulness  or  marked  dulness,  especially 
if  areas  of  collapse  are  present  with  pneumonia.  Sometimes  the  note 
over  the  rest  of  the  thorax,  behind  especially,  is  vesiculo-tympanitic. 
It  the  areas  of  collapse  are  small,  no  dulness  is  elicited. 

Auscultation. — In  areas  situated  at  the  apex  or  toward  the  base 
of  the  lung  the  air  does  not  seem  to  enter  freely  on  inspiration,  and 
the  expiratory  sound  is  hardly  audible  (collapse  of  area)  or  absent. 
Breathing  is  otherwise  puerile  or  exaggerated,  rarely  bronchial. 


200  DISEASES  OF  THE  NEWBOBN. 

Very  fine  subcrepitant  rales  are  heard  in  various  parts  of  the 
lung.  Crepitant  rales  are  very  distinctly  heard  in  other  areas,  and 
are  distinguished  from  the  coarser  subcrepitant  rales  by  their  fine 
quality.  Areas  of  pneumonia  can  thus  be  recognized  by  the  fine 
crepitations ;  the  atelectasis,  by  the  absence  of  respiratory  sounds  and 
dulness.  Voice  sounds  vary  greatly.  When  the  infant  cries  the 
vocal  resonance  may  seem  increased,  and  again  normal ;  or  if  the 
pneumonic  area  is  extensive  and  is  in  the  vicinity  of  a  large  bronchus, 
V7e  may  have  tubular  resonance. 

Temperature. — Temperature  is  often  normal  or  subnormal ;  later, 
it  may  be  elevated. 

Convulsions. — Convulsions  are  common  in  atelectasis;  in  fact, 
they  are  peculiar  to  the  disease.  They  are  repeated  at  frequent  in- 
tervals, and  an  infant  may  have  three  or  four  attacks  of  general  con- 
vulsions in  the  course  of  the  twenty-four  hours.  At  the  onset  of  the 
convulsions  the  cyanosis  increases. 

Diagnosis. — The  diagnosis  is  not  possible  if  the  area  of  collapse 
of  the  lung  be  small.  If  of  considerable  extent  and  giving  rise  to 
physical  signs,  the  diagnosis  may  be  made. 

As  a  rule,  the  congenital  forms  of  atelectasis  are  more  extensive 
than  the  acquired  forms,  and  thus  can  be  more  readily  detected. 

The  diagnosis  of  post-natal  congenital  atelectasis  vs^ill  depend  upon : 

Convulsions. — Given  the  case  of  a  newborn  infant  delivered  with- 
out forceps  or  force,  in  the  absence  of  signs  of  any  other  disease,  such 
as  hemorrhage  on  the  surface  of  the  brain,  the  presence  of  repeated 
convulsions,  with  cyanosis  and  dyspnoea  in  the  intervals,  the  possi- 
bility of  atelectasis  should  be  considered. 

The  presence  of  areas  of  slight  dulness,  or  tympanitic  dulness,  or 
vesiculo-tympanitic  resonance  all  over  the  chest. 

Fine  subcrepitant  rales. 

Still  finer  crepitant  rales. 

Areas  in  which  the  air  enters  incompletely. 

Prognosis. — There  is  no  reason  why  an  atelectatic  area  of  the  con- 
genital variety  should  not  return  to  the  normal  if  the  cause  of  its 
existence  is  removed  and  the  infant  regains  power  to  inflate  the  lung. 
The  same  may  be  said  of  the  acquired  form  of  atelectasis. 

Treatment. ^ — The  treatment  must  be  directed  toward  stimulating 
the  heart  and  increasing  the  respiratory  efforts  if  the  infant  is  weak 
or  premature.  If  the  heart  is  weak,  the  treatment  is  much  the  same 
as  in  bronchopneumonia.  If  the  infant  does  not  breathe  satisfac- 
torily, it  is  well  to  make  it  cry  vigorously  several  times  in  the  twenty- 
four  hours,  so  that  the  collapsed  area  of  lung  may  be  inflated  and  the 
mucus  in  the  bronchi  expelled.  Unless  made  to  cry,  these  infants  lie 
torpid  and  hardly  seem  to  breathe.     The  areas  of  atelectasis  are  thus 


SEPTIC  INFECTION  OF  THE  NEWBORN  INFANT.  201 

increased.  If  the  temperature  is  subnormal  and  the  infant  seems 
chilled,  we  may  stimulate  it  by  the  application  of  heat  externally, 
either  by  means  of  warm  baths,  hot-water  bottles,  or  an  incubator. 

SEPTIC    INFECTION    OF    THE    NEWBORN    INFANT. 

Our  views  on  the  subject  of  septic  infection  of  the  newborn  have 
undergone  considerable  change  in  the  last  decade.  The  former  clas- 
sification of  certain  processes,  such  as  pyaemia,  septicopy£emia,  and 
pyogenic  infection,  has  given  way  to  a  greater  or  less  extent  to 
broader  views. 

By  septic  infections  are  meant  certain  general  phenomena  pro- 
duced by  bacterial  toxins,  or  by  the  entry  of  bacteria  into  the  body 
by  way  of  the  blood  or  lymphatic  channels.  The  newborn  infant 
is  particularly  susceptible  to  infection.  At  this  period  of  life  the 
ordinary  means  of  defence  are  lacking,  the  lymph  nodes  and  spleen 
are  undeveloped,  the  skin  is  in  a  very  vulnerable  state  and  is  a  ready 
avenue  of  entrance  for  bacteria,  as  are  also  the  mucous  membranes. 
The  lack  of  febrile  reaction,  also,  demonstrates  that  in  the  newborn 
there  is  little  resistance  against  the  invasion  of  bacteria.  Septic 
infections  may  appear  under  the  semblance  of  a  diarrhoea,  bronchitis, 
pneumonia,  hemorrhagic  conditions,  such  as  Winckel's  or  Buhl's  dis- 
ease, and  dermatitis  exfoliativa,  all  of  which  are  really  manifesta- 
tions of  sepsis. 

Etiology. — The  most  frequent  causes  of  septic  infection  are  the 
pyogenic  bacteria,  the  streptococci  and  staphylococci.  Following 
these  in  order  of  importance  are  the  bacilli  of  the  coli  group,  the 
pneumococci,  bacilli  of  general  hemorrhagic  infection  (Babes),  the 
bacillus  pyocyaneus  (ISTeumann),  the  capsule  bacillus  of  Dungern, 
the  bacillus  enteritidis  (Gartner),  found  in  hemorrhagic  aifections 
resembling  Winckel's  disease,  and  the  bacillus  of  Finkelstein,  found 
also  in  hemorrhagic  conditions.  The  bacteria  exist  in  the  air  of 
hospital  wards  (Emmerich,  Babes,  Gartner,  Prudden),  They  are 
found  in  the  normal  breast  milk  (ISTeumann),  and  in  the  milk  of 
breasts  which  are  the  seat  of  ulceration,  fissure,  or  abscess.  The  body 
of  the  mother,  the  lochia,  and  also  the  liquor  amnii  after  rupture  of 
the  membranes,  are  all  sources  whence  bacteria  may  gain  access  to 
the  body  of  the  newborn  infant.  As  a  rare  source  of  infection  may 
be  mentioned  the  incubator  in  which  septic  cases  have  been  nursed 
(Allard).  The  bath-water  has  been  the  means  of  causing  epidemics 
of  dermatitis  exfoliativa  and  Winckel's  disease  among  infants  in 
institutions. 

Hetero-infection  may  also  be  mentioned,  such  as  obtains  at  the 
hands  of  the  accoucheur,  from  unclean  instruments  and  dressings. 


202  DISEASES  OF  THE  NEWBORN. 

Among  the  aiitoinfections  may  be  mentioned  the  conditions  which 
obtain  in  the  skin  of  the  infa^it,  which  is  in  process  of  desquamation. 
Deprived  of  its  horny  layer,  which  is  absent  in  the  newborn,  bacteria 
can  penetrate  the  sudoriparous  and  sebaceous  follicles.  Thus,  any 
pustule  may  give  rise  to  a  general  or  local  process. 

Umhilical  Site. — The  umbilical  site  is  not  considered  as  frequent 
an  avenue  of  infection  as  in  former  days  when  puerperal  disease  was 
more  common.  To-day  we  have  occasional  epidemics  of  umbilical 
as  well  as  other  forms  of  infection;  but  with  modern  methods  this 
form  of  infection  has  become  more  and  more  infrequent. 

Bacteria  or  their  toxins  may  thus  gain  access  to  the  body  through 
the  intact  or  wounded  skin,  the  umbilicus,  the  mucous  membranes 
(buccal  or  pharyngeal),  through  the  lungs  in  the  respired  air,  through 
the  digestive  tract  by  means  of  the  food,  through  the  conjunctivae  and 
the  ears,  and  finally  through  the  genital  tract. 

Respiratory  autoinfections  occur  through  the  aspiration  of  liquor 
amnii  or  vaginal  secretions.  Bacteria  may  gain  access  through  a 
minute  loss  of  the  lining  epithelium  of  the  respiratory  tract. 

Digestive  Infections. — These  must  be  regarded  as  rare.  The 
manner  in  which  the  bacteria  gain  access  to  the  circulation  from  the 
gut  has  been  demonstrated  by  Booker  and  Escherich.  They  have 
shown  that  streptococci  may  gain  access  to  the  general  circulation  by 
way  of  lesions  of  the  mucous  membrane  of  the  gut. 

Conjunctivallnfection. — Conjunctival  infection,  except  in  specific 
cases,  is  rare. 

Otogenic  Infection. — The  ears  may  be  the  seat  of  septic  infection, 
for  pus  has  been  found  in  the  ear  of  the  newborn,  and  thence  has 
entered  the  general  circulation  through  infection  of  the  lateral  sinus, 
causing  sinus  thrombosis,  meningitis,  and  encephalitis. 

Urogenital  Infection. — This  may  occur  by  way  of  the  urogenital 
tract.  As  first  pointed  out  by  Epstein,  an  inflammation  of  the  vagina, 
bladder,  or  kidneys  may  be  a  starting-point  of  general  infection. 

Among  the  predisposing  causes  of  infection  of  the  newborn  must 
be  considered  congenital  weakness.  Thus,  the  greatest  number  of 
cases  occur  among  the  weakly  infants  of  syphilitic  or  tuberculous 
parentage,  premature  infants,  and  those  possessing  birth  anomalies. 

Symptoms. — It  is  impossible  to  particularize  any  form  of  sepsis  so 
far  as  the  general  symptoms  are  concerned.  The  reaction  in  the  newborn 
infant  is  so  imperfect  and  the  signs  are  so  equivocal  that  it  is  often 
only  at  the  autopsy  table  that  the  nature  of  the  lesion  is  determined. 
It  will  be  convenient,  therefore,  simply  to  enumerate  the  objective 
changes  noted  in  the  various  structures  of  the  body  in  this  disease. 

Skin. — The  skin  may  be  dry,  or  the  seat  of  localized  oedema  or 
sclerema.     It  may  be  the  seat  of  erythema,  either  on  the  body  or  on 


PLATE   VII 


'v^__:/^^-^^// 


Sepsis  in  the  Newborn  Infant.  Suppuration  of  the 
right  knee-joint.  Osteomyelitis  of  the  epiphyses  of  the 
bones  forming  the  joint. 


SEPTIC  INFECTION  OF  THE  NEWBOBN  INFANT.  203 

the  extensor  surface  of  the  arms  or  hands.  There  is  sometimes  a 
general  or  localized  cyanosis,  A  peculiar  form  of  this  cyanosis  has 
been  described  by  Finkelstein — the  so-called  angiospastic  cyanosis — 
in  which  a  central  pallor  and  peripheral  lividity  are  present  in  the 
patches.     The  cyanosis  may  be  limited  to  the  hands  and  feet. 

Eruptions  of  a  pemphigoid  character  are  sometimes  seen  in  cases 
of  sepsis  of  the  newborn  infant.  The  vesicles  may  be  the  seat  of 
suppuration,  or  there  may  be  ulcers  and  intertrigo  varying  from 
superficial  erosions  to  extensive  areas  of  gangrene.  The  skin  may 
be  i^ale  or  icteric  in  hue.  There  may  be  erysipelatous  patches,  fur- 
uncles, and  multiple  abscesses. 

Mouth. — The  mucous  membrane  of  the  mouth  is  dry  and  fissured, 
and  the  tongue  dry  and  coated.  The  roof  of  the  mouth  may  be  the 
seat  of  ulcerations,  superficial  or  deep,  occurring  at  the  median  raphe, 
where  we  find  normally  Epstein's  pearls,  or  laterally  over  the  hamular 
processes  of  the  palate  bone  (Bednar's  aphthse).  The  mouth  may 
be  the  seat  of  pseudomembranous  deposit  not  due  to  the  diphtheria 
bacillus  (Epstein).  In  these  cases  of  sepsis  sprue  may  engraft  itself 
on  the  mucous  membrane  of  the  mouth  and  extend  to  the  pharynx, 
oesophagus  and  stomach. 

Vagitia. — The  vagina  in  female  infants  may  be  the  seat  of  catar- 
rhal or  pseudomembranous  inflammation. 

Umbilicus. — ISTormally,  pathogenic  bacteria  are  found  about  the 
stump  of  the  desiccating  cord,  but  do  no  harm ;  under  favorable  con- 
ditions of  sepsis,  however,  these  bacteria  may  increase  in  numbers 
and  virulence  and  become  a  source  of  great  danger.  In  septic  condi- 
tions the  cord  does  not  fall  off  promptly.  The  tissues  about  the 
umbilicus  are  inflamed  and  the  seat  of  phlegmon  and  suppuration. 
Pus  may  burrow  downward  toward  the  bladder  along  the  course  of 
the  foetal  structures.  The  bloodvessels  of  the  cord  may  be  the  seat 
of  inflammation,  as  wull  be  shown  later.  In  some  forms  of  sepsis 
in  which  the  infectious  material  may  have  gained  entrance  through 
the  umbilicus,  the  latter  may  show  absolutely  no  change  from  the 
normal. 

Bones  and  Joints. — There  may  be  swelling  in  the  muscles  about 
the  joints,  as  in  forms  of  intramuscular  abscess,  or  the  joint  itself 
may  be  the  seat  of  septic  suppuration  or  so-called  osteomyelitis  (Plate 
VII. ) .  The  shaft  of  the  bone  or  the  epiphysis  only  may  be  involved. 
One  or  many  joints  may  be  the  seat  of  suppuration. 

Nervous  System. — Functional  symptoms,  such  as  apathy,  restless- 
ness, or  convulsions,  may  be  present,  or  there  may  be  localized  facial 
paralysis  or  paralysis  of  the  extremities,  traceable  to  meningitis  or 
encephalitis.  Hemorrhages  in  forms  of  sepsis  may  give  rise  to 
paresis  simulating  the  traumatic  palsies  of  the  newborn. 


204         '  DISEASES  OF  TEE  NEWBORN. 

Respiratory  Tract. — The  respiratory  tract  may  present  catarrhal 
or  pseudomembranous  inflammation  of  the  nose,  tonsils,  larynx,  or 
trachea.  The  bronchitis  and  pneumonia,  especially  in  the  septic 
forms  of  diarrhoea,  may  be  of  obscure  nature  and  run  an  insidious 
course. 

The  bronchopneumonia  which  accompanies  sepsis  of  the  newborn 
is  septic  in  its  nature,  with  but  little  febrile  reaction  and  dyspnoea. 
Pleurisy  and  abscess  of  the  lung  may  occur,  but  are  frequently  only 
discovered  at  the  autopsy  table. 

Circulatory  System. — The  heart  may  be  the  seat  of  septic  endo- 
pericarditis.     This  form  of  pericarditis  is  rarely  diagnosed. 

Stomach  and  Intestines. — The  intestinal  tract  may  be  the  seat  of 
a  septic  diarrhoea.  There  may  be  vomiting  with  severe  gastro- 
intestinal symptoms,  not  infrequently  with  blood  in  the  vomited 
matter  as  a  manifestation  of  toxEemia.  In  the  cases  of  septic  diar- 
rhoea described  by  Fischl  and  Czerny  there  was  complicating  broncho- 
pneumonia of  a  severe  type. 

Liver. — The  liver  may  be  the  seat  of  enlargement  in  cases  of 
extended  duration,  but  the  spleen  is  rarely  so. 

Urine. — The  urine  may  contain  albumin  and  blood,  not  infre- 
quently leucocytes  and  casts,  indicating  a  septic  nephritis. 

Body-weight. — The  body-weight  diminishes  markedly  and  rapidly. 

Temperature. — The  temperature  is  not  characteristic.  In  the 
severest  forms  of  sepsis  it  may  be  normal  or  subnormal;  in  other 
cases  there  may  be  a  rise  of  a  degree  or  more.  I  have  seen  this  in 
milder  cases.  A  new  complication  may  be  ushered  in  with  a  rise 
of  temperature,  as  often  happens  with  older  infants  and  children,  but 
this  is  not  necessarily  so. 

Hemorrhages  in  the  Eye. — In  some  cases  examination  of  the 
fundus  oculi  shows  the  presence  of  hemorrhages. 

Morbid  Anatomy. — The  changes  in  the  skin  have  been  described. 
Those  of  the  umbilicus  will  be  found  under  the  section  of  Umbilical 
Infection.  The  appearances  in  the  mouth,  nose,  and  throat  have 
been  described,  as  well  as  those  of  the  lungs.  The  alterations  in  the 
gastroenteric  tract  are  detailed  in  the  chapter  on  Diseases  of  the 
Gastroenteric  Tract. 

The  liver  and  kidneys  are  the  seat  of  parenchymatous  or  diffuse 
suppurative  changes.  The  peritoneum  is  ordinarily  intact,  although 
formerly  authors  believed  it  to  be  frequently  involved.  The  peri- 
cardium, endocardium,  and  myocardium  may  be  the  seat  of  slight 
or  marked  changes.     Blood  cultures  may  reveal  the  infecting  bacteria. 

Diagnosis. — The  origin  of  some  cases  of  sepsis  of  the  newborn 
infant  is  so  obscure  that  not  only  is  a  diagnosis  made  with  difficulty, 
but  it  is  not  always  possible  to  determine  .the  point  of  entrance  of 


SEPTIC  INFECTION  OF  THE  NEWBOBN  INFANT.  205 

the  infectious  agent.  In  cryptogenetic  cases  no  lesion  may  be  visible. 
If  an  infant  cries  when  it  is  diapered  or  washed  in  the  bath,  the 
joints  should  be  examined  for  suppuration.  A  pseudomerabranous 
deposit  or  an  ulceration  in  the  mouth  is  a  sign  of  traumatism  with 
infection.  A  diarrhoea  in  the  newborn  infant  is  of  serious  moment. 
The  umbilicus,  if  swollen  or  red,  should  receive  due  consideration. 
Lumbar  puncture  has  been  proposed  for  the  examination  of  the  cere- 
brospinal fluid  for  micro-organisms,  but  this  is  hardly  justifiable 
unless  a  meningitis  be  present.  It  has  been  suggested  that  the  blood 
should  be  examined  for  micro-organisms  by  means  of  culture.  In 
several  of  my  cases  in  which  this  was  attempted  it  was  impossible  to 
obtain  the  requisite  amount  of  blood  sufficient  for  a  culture,  the 
vessels  being  quite  small  at  this  age,  and  it  being  deemed  inadvisable 
to  enter  an  artery  or  a  very  large  vein  in  order  to  obtain  the  requisite 
amount  of  blood. 

Puncture  of  the  spleen  for  the  detection  of  micro-organisms  has 
been  advised.  Such  a  procedure  may  or  may  not  be  advisable, 
according  to  the  indications  in  the  case. 

Course  and  Prognosis. — Some  forms  of  acute  sepsis  prove  fatal  in 
a  few  hours.  Others,  and  they  are  the  most  common,  last  from  a 
few  days  to  a  week.  Others  give  no  symptoms  and  result  in  sudden 
death  of  the  infant.  Finally,  the  subacute  cases,  which  are  compli- 
cated with  progressive  emaciation,  diarrhoea,  and  pneumonia,  extend 
over  two  or  more  weeks.  Septic  osteomyelitis  and  chronic  omphalitis 
are  especially  protracted.  The  prognosis  in  these  cases  is  always 
grave.  Mild  forms  of  intestinal  sepsis,  after  pursuing  a  short  course 
with  fluctuating  temperature,  may  recover  completely. 

In  subacute  cases  the  danger  of  complications  is  ever  present. 
Even  if  bacteria  are  found  to  be  present  in  the  blood,  a  recovery  is 
not  always  impossible. 

Treatment. — There  is  no  specific  treatment  for  sepsis  in  the  new- 
born infant.  Prophylaxis  is  of  the  utmost  importance.  The  hands 
of  the  accoucheur  must  be  as  clean  in  handling  the  newborn  infant 
as  in  the  treatment  of  the  mother.  The  cord  is  tied  with  precautions 
described  elsewhere.  The  mouth  is  not  washed.  As  Epstein  has 
pointed  out,  Bednar's  aphthse  and  pseudomembranous  inflammations 
are  thus  avoided.  The  nasal  passages  are  not  inspected  more  than 
is  absolutely  necessary.  The  bath-water  should  be  clean  and  not 
below  38°  C.  (100°  F.).  The  food  should  receive  attention.  The 
infant  should  not  nurse  a  fissured  or  an  inflamed  breast.  The  breast 
nipple  should  be  cleansed  before  and  after  nursing,  as  stated  in  the 
section  on  Hygiene.  The  room  in  which  the  child  sleeps  should  be 
ventilated.  Contact  with  the  secretion  of  the  mother  (lochia)  should 
be  avoided. 


206         '  DISEASES  OF  THE  NEWBORN. 

Therapeutic  measures  will  be  directed  toward  the  indication  in 
each  case.  If  a  pneumonia  or  gastroenteritis  be  present,  this  com- 
plication is  treated  on  the  same  lines  as  a  primary  infection  of  a 
similar  nature.  Osteomyelitis  resulting  in  an  accumulation  of  pus 
in  the  joints  will  receive  surgical  treatment.  Cases  complicated  by 
meningitis  also  will  receive  the  treatment  indicated  under  the  section 
on  Meningitis  as  a  Primary  Infection.  If  the  indications  exist,  such 
as  pressure  effects,  a  lumbar  puncture  may  be  performed.  Abscesses 
are  opened  and  erysipelatous  and  purulent  skin  lesions  treated  accord- 
ing to  surgical  procedure  in  each  case. 

The  strength  should  be  supported,  and  for  this  purpose  alcohol 
may  be  used  with  small  doses  of  strychnine.  The  antistreptococcic 
sera  are  of  doubtful  efficacy.  The  administration  of  alkalies,  such  as 
the  salicylate,  benzoates,  and  carbonate  of  sodium,  has  been  strongly 
advocated.  High  saline  enemata  are  of  value.  Subcutaneous  and 
intravenous  saline  injections  have  not  proved  successful. 

DISEASES    OF    THE    UMBILICUS. 

Diseases  of  the  umbilicus  are  classified  as  those  which  are  purely 
local,  such  as  blenorrhoea,  phlegmon,  gangrene,  and  erysipelas;  those 
which  begin  as  a  local  lesion  and  result  in  a  general  infection,  such 
as  arteritis  and  phlebitis  umbilicalis,  hemorrhage  from  the  umbilicus  ; 
and,  finally,  those  which  may  be  classified  as  anatomical  deficiencies, 
the  hernise  umbilicales. 

Omphalitis. — The  umbilical  cord  dries  up  and  drops  off  in  five 
days,  leaving  a  granulating  stump.  In  the  case  of  weakly  infants 
the  cord  may  not  fall  off  until  much  later.  The  stump  may  become 
inflamed  and  pus  may  form.  This,  in  the  majority  of  cases,  is  due 
to  infection. 

Infection  of  the  site  of  the  ligature  of  the  umbilical  cord  may 
easily  occur  in  the  newborn,  first,  because  bacteria  are  normally 
present,  or  may  be  conveyed  to  the  site  not  only  at  the  time  of  liga- 
tion of  the  cord,  but  after  the  stump  has  separated  and  the  cord 
healed.  Infection  usually  takes  place  at  the  time  of  ligation  or 
before  the  cord  separates  from  the  stump.  The  appearance  of  the 
,  stump  in  omphalitis  varies.  In  some  cases  the  inflammation  is 
slight,  but  in  others  the  tissues  are  red,  infiltrated,  and  coated  with 
necrotic  masses  resembling  pseudomembrane.  ISTumerous  small 
abscesses  may  be  present.  The  great  danger  is  that  the  process  may 
involve  the  umbilical  vessels.  If  the  inflammation  remains  local, 
recovery  is  the  rule.     If  the  vessels  become  involved,  sepsis  may  result. 

Treatment. — Proper  ligation  and  care  in  dressing  the  cord  will  in 
most  cases  prevent  subsequent  infection.     Cleanliness  is  of  the  first 


DISEASES  OF  THE  UMBILICUS.  207 

importance.  The  hands,  instruments,  and  the  tape  used  for  ligation 
should  be  scrupulously  clean.  The  care  of  the  stump  of  the  umbilical 
cord  has  been  a  matter  of  much  discussion.  The  ideal  method  of 
dressing  the  stump  has  not  as  yet  been  found.  Some  prefer  not  to 
bathe  the  child  until  after  the  stump  has  separated,  in  order  to 
facilitate  the  mummification  of  the  cord;  others  insist  that  if  the 
dressing,  hands,  and  water  are  clean,  no  danger  results  from  the 
bath,  and  a  daily  dressing  of  the  cord  is  not  improper.  This  will 
be  taken  up  elsewhere.  If  the  cord  is  dressed  daily,  it  should  be 
dusted  with  some  bland  powder,  such  as  dermatol,  orthoform,  or 
xeroform,  even  after  the  stump  has  separated  and  until  the  wound 
is  completely  healed,  for  the  site  of  the  umbilical  cord  is  susceptible 
of  infection  even  after  the  healing  has  taken  place.  The  best  dressing 
for  the  cord  is  sterilized  absorbent  gauze  several  layers  thick,  and 
perforated  in  the  centre.  The  cord  is  passed  through  this  perfora- 
tion and  enclosed  in  the  gauze.  This  dressing  is  renewed  daily.  If 
a  suppurating  surface  appears,  it  should  be  treated  on  general  sur- 
gical principles.  As  a  rule,  ointments,  should  be  avoided.  The 
ordinary  sterilized  wet-dressing  is  sufficient. 

Umbilical  Fungus  (Granuloma). — In  some  cases  the  stump  does 
not  heal  after  the  cord  has  separated,  and  a  granulating  surface 
which  presents  a  fungoid  appearance  remains.  The  granulating 
mass  may  become  as  large  as  a  bean  and  be  pedunculated.  There  is 
secretion  of  pus.  The  affection  is  a  benign  one,  and  should  not  be 
confounded  with  the  so-called  enteratomata ,  which  are  rare.  The 
latter  are  composed  of  smooth  muscular  fibre  and  tubular  glands. 
These  umbilical  tumors  have  been  described  by  Kolaczek,  who  believes 
that  they  are  formed  by  the  prolapsus  of  a  persistent  omphalomesen- 
teric duct.  Von  Heukelom  asserts  that  they  are  intestinal  protru- 
sions through  true  diverticula  of  Meckel.  Adenoid  tumors  of  the 
umbilicus  have  been  described  by  Lannelongue  and  Fremont.  Hiit- 
tenbrenner  has  reported  a  polypoid  tumor  of  the  umbilicus,  which  he 
believed  to  be  the  remains  of  the  allantois. 

Treatment. — If  small  and  flat,  the  granulations  are  touched  daily 
with  silver  nitrate  stick  and  a  dry  dressing  is  applied ;  or  the  granula- 
tions may  be  carefully  scraped  off  and  the  stump  dressed  with  steri- 
lized gauze  after  bleeding  has  ceased.  If  the  growth  is  large  and 
pedunculated,  it  should  be  ligated  at  its  base  with  silk  or  catgut  and 
a  sterile  gauze  dressing  applied.  In  a  day  or  two  the  mass  separates 
and  healing  takes  place. 

Blennorrhcea  of  the  Umbilicus.- — Blennorrhoea  of  the  umbilicus 
is  a  condition  in  which  there  is  considerable  suppuration  and  secre- 
tion of  pus  after  the  stump  of  the  umbilical  cord  has  separated. 
The  area  of  skin  around  the  umbilicus  is  red  and  excoriated.  Under 
proper  treatment  this  condition  is  curable. 


208  DISEASES  OF  THE  NEWBORN. 

Phlegmon  of  the  Umbilicus. — This  is  an  inflammatory  reaction 
of  the  umbilical  wound  due  to  some  local  infection.  There  is  an 
omphalitis  umbilicalis.  The  region  of  the  umbilical  wound  is  red, 
inflamed,  and  infiltrated,  as  is  also  the  neighboring  skin.  There  is 
pain.  The  condition  may  retrograde  or  the  sMn  may  break  down 
and  ulcerate,  or  abscesses  may  cause  infection  of  the  peritoneum.  In 
the  latter  case  the  disease  is  invariably  fatal. 

Ulcer  of  the  Umbilicus. — The  umbilical  wound  is  here  replaced 
by  an  ulcer  of  an  irregular  shape ;  the  neighboring  skin  is  red  and 
swollen,  and  there  is  a  discharge  of  discolored  pus.  There  is  pain, 
uneasiness,  and  fever,  or  there  may  be  no  temperature.  In  some 
cases  ulcers  may  exist  with  a  pseudomembranous  deposit.  The  dis- 
ease, however,  has  nothing  in  common  with  true  diphtheria,  but  is 
due  to  wound  infection  of  a  streptococcic  nature.  The  umbilical 
wound  may  become  infected  with  di]Dhtheria.  In  such  a  case  the 
diphtheria  bacilli  will  be  found  in  the  discharge  and  in  the  mem- 
brane on  the  wound. 

Gangrene  of  the  Umbilicus. — This  is  a  very  serious  condition, 
and  occurs  in  weak  infants  amid  unhygienic  surroundings.  The 
disease  may  develop  in  from  six  to  thirty  days  after  birth ;  the  wound 
becomes  bluish  or  greenish  red,  discolored,  or  is  converted  into  a  dis- 
colored, greenish,  bloody  mass  secreting  ichorous  pus.  The  gan- 
grenous process  may  involve  the  skin,  and  usually  spreads  into  the 
depths  of  the  abdominal  wall,  involving  the  urachus,  the  umbilical 
vessels,  and  finally  the  peritoneum.  The  prostration  is  great,  and 
there  may  be  little  or  no  temperature ;  or  the  temperature  may  even 
be  subnormal.  Under  these  conditions  there  results  a  general  sepsis, 
and  the  infant  dies  of  toxaemia  or  complicating  peritonitis.  In  some 
cases  the  gangrenous  process  begins  in  the  subcutaneous  tissues, 
spreads  thence  to  the  peritoneum,  the  overlying  skin  remaining  toler- 
ably intact.  This  latter  form  of  necrosis  is  only  discovered  and 
verified  postmortem. 

Treatment. — The  treatment  of  blennorrhoea  of  the  umbilicus  con- 
sists in  applying  some  dry  dressing  with  a  dusting  powder,  such  as 
dermatol.  By  applying  this  powder  daily  the  condition  is  generally 
controlled. 

Phlegmon  of  the  umbilicus  is  treated  in  the  same  manner  as  an 
ordinary  phlegmon,  by  means  of  any  convenient  wet  dressing.  Liquor 
Burrowii  or  Thiersch's  solution  forms  a  very  convenient  dressing. 

Ulcer  of  the  umbilicus  is  treated  by  means  of  wet  dressing,  or 
by  the  application  of  one  part  of  balsam  of  Peru  to  four  parts  of 
castor  oil,  applied  on  gauze.  The  balsam-and-oil  dressing  is  certainly 
very  agreeable,  and  successful  in  many  cases. 

Gangrene  of  the  umbilicus  is  treated  on  surgical  principles  in  the 
same  manner  as  gangrene  in  other  parts  of  the  body. 


DISEASES  OF  THE  UMBILICUS.  209 

Erysipelas  of  the  Umbilicus. — This  affection  may  involve  the 
umbilicus  and  spread  thence  to  the  surrounding  skin.  It  may,  how- 
ever, remain  local ;  but,  as  a  rule,  it  spreads,  involves  most  of  the 
surface  of  the  abdomen,  and  in  many  cases  ends  in  gangi'ene.  If 
erysipelas  remains  localized,  recovery  may  result;  if  it  spreads,  how- 
ever, it  is  generally  fatal. 

Infection  of  the  Umbilical  Vessels  (Arteritis  TJmhilicalis). — 
Etiology. — This  is  an  infection  which  may  take  place  before  or  after 
the  separation  of  the  umbilical  stump,  and  may  occur  by  way  of  the 
bloodvessels  or  the  perivascular  connective  tissue  of  the  cord. 

In  this  affection  the  perivascular  connective  tissue  of  the  cord 
may  first  become  infiltrated  with  serum  and  be  cedematous ;  later,  the 
various  coats  of  the  arteries  are  affected.  Thrombosis  results,  with 
disintegration  of  the  thrombi.  The  lymph-vessels  in  the  connective 
tissue  of  the  cord  carry  the  infectious  material  to  the  various  parts 
of  the  body. 

It  must  not  be  forgotten  that  the  normal  stump  of  the  cord  con- 
tains bacteria;  to  be  sure,  of  the  non-virulent  type  or  of  reduced 
virulence.  These  cause  no  trouble.  Given,  however,  uncleanliness, 
either  in  the  dressings  or  otherwise,  these  bacteria  combined  with 
others  may  give  rise  to  serious  infection.  The  lochia,  though  not 
frequently,  may  be  a  source  of  infection.  This  infrequency  is  due 
to  our  means  of  asepsis,  and  to  the  protection  which  our  present 
methods  afford  against  epidemics  of  umbilical  infection. 

Umbilical  arteritis  is  a  wound  infection.  It  is  most  frequently 
seen  in  institutions,  and  is  the  result  of  implantation  of  septic  matter 
on  the  umbiKcal  wound  by  the  hands  or  instruments,  or  through  the 
bath-water  or  unclean  dressings.  Cases  have  occurred  coincident 
with  the  presence  of  blennorrhoea. 

Morbid  Anatomy. — There  may  be  simple  ulceration  with  discolor- 
ation of  the  umbilicus  and  purulent  material  in  the  lumen  of  the 
artery,  with  infiltration  of  perivascular  tissue.  The  vessels  running 
from  the  umbilicus  appear  as  thickened  discolored  cords.  The  peri- 
vascular tissue  is  infiltrated.  The  process  may  begin  about  a  centi- 
metre behind  the  umbilicus  and  extend  downward  toward  the  bladder. 
The  umbilical  stump  may  be  normal  in  appearance  or  inflamed.  The 
lumen  of  the  arteries  contain  thrombi.  The  vessels  may  be  dilated 
and  contain  disintegrated  purulent  masses.  There  may  be  lobar  or 
lobular  pneumonia,  with  pleurisy  and  hemorrhagic  infarction  of  the 
lung.  Parenchymatous  inflammation  of  the  liver,  kidney,  and  spleen 
and  suppuration  of  one  or  several  joints  (see  Osteomyelitis)  may  be 
observed.     Peritonitis  may  be  a  complication. 

The  bacteria  found  in  most  of  these  cases  have  been  streptococci 
or  staphylococci. 

14 


210  DISEASES  OF  THE  NEWBOEN. 

There  may  be  metastatic  abscesses  in  the  various  organs ;  the 
tissue  of  the  heart  may  be  the  seat  of  parenchymatous  degeneration ; 
the  epi-  and  pericardium  may  be  the  seats  of  ecchymoses  and  hemor- 
rhages, as  also  the  pleura.  There  may  be  suppuration  in  the  cavity 
of  the  pleura. 

Organs  apparently  normal  in  gross  appearance  may  be  the  seat 
of  parenchymatous  degeneration. 

Symptoms. — The  symptoms  of  arteritis  umbilicalis  are  often  in- 
definite and  give  no  clue  to  the  cause  of  the  illness.  The  infants 
gTadually  emaciate  and  succumb,  the  fatal  issue  supervening  quite 
suddenly.  The  umbilicus  may  in  these  cases  have  been  long  healed 
and  show  no  evidence  of  disease ;  in  other  cases  it  is  inflamed.  There 
is  a  sinus  leading  downward  and  backward  toward  the  bladder,  and 
from  this  pus  exudes.  A  tense  cord-like  structure,  the  inflamed 
umbilical  vessels,  is  felt  beneath  the  abdominal  wall.  Sometimes  the 
first  intimation  of  serious  disease  is  seen  in  the  joints.  The  mother 
may  tell  the  physician  that  the  infant  cries  when  it  is  bathed  or 
dressed.  In  these  cases  the  knee,  ankle,  or  hip  may  be  swollen,  tense, 
and  the  seat  of  exudate.  A  septic  osteomyelitis  of  the  epiphyses  of 
the  joint  is  present,  resulting  in  a  suppurative  arthritis.  As  a  rule, 
more  than  one  joint  is  involved.  In  other  cases  the  symptoms  are 
indefinite :  there  is  a  slight  febrile  movement.  The  skin  has  a  slightly 
gray  or  icteric  hue  and  may  be  the  seat  of  erythema  or  hemorrhages, 
as  mentioned  under  the  heading  of  Sepsis,  There  may  be  a  violent 
gastroenteritis  or  rapidly  fatal  pneumonia,  or  the  lung  symptoms  may 
be  equivocal  and  not  very  marked.  In  other  words,  there  is  a  sepsis 
with  the  symptom-complex  of  a  pneumonia  or  gastroenteric  dis- 
turbance. 

Hennig's  symptom,  which  consists  of  a  so-called  depressed  triangle 
reaching  from  the  umbilicus  to  the  pubis,  bounded  by  red  lines  indi- 
cating the  inflamed  arteries,  accompanied  by  oedema  of  the  wall  of 
the  abdomen,  is  not  always  present  or  to  be  depended  upon. 

Course.^ — The  cases  may  be  classed  as  acute,  resembling  sepsis 
and  running  a  very  rapidly  fatal  course,  simulating  a  diarrhoea  or 
pneumonia.  Other  cases  may  recover ;  these  are  the  mild  infections. 
The  uncommon  cases  are  those  which  run  a  chronic  or  subacute  course 
with  metastatic  abscesses  throughout  the  body. 

Prognosis. — These  cases  are  generally  fatal,  A  few  of  the  mild 
cases  recover.  In  these,  however,  it  is  a  question  as  to  whether  the 
vessels  have  been  involved  or  whether  there  was  a  true  infection  of 
a  septic  nature.  The  prognosis  is  especially  unfavorable  in  prema- 
ture infants. 

Phlebitis  Umbilicalis. — In  this  affection  the  veins  which  pass 
from  the  umbilicus  to  the  liver  are  the  seat  of  an  inflammatory 


DISEASES  OF  THE  UMBILICUS.  '  211 

process  similar  to  that  affecting  the  arteries  in  the  affection  just 
described.  There  is  a  true  phlebitis,  with  pus  in  the  lumen  of  the 
veins,  in  some  cases  extending  into  the  liver.  The  branches  of  the 
portal  vein  are  involved.  The  picture  presented  is  that  of  metastatic 
abscesses,  as  contradistinguished  from  the  parenchymatous  degenera- 
tions which  make  up  the  picture  of  arteritis  umbilicalis.  The  umbil- 
ical vein  is  dilated  and  filled  with  pus ;  the  intima  is  swollen,  inflamed, 
or  eroded;  the  suppuration  extends  to  the  liver,  which,  with  the 
spleen  and  kidneys,  may  be  the  seat  of  metastatic  abscesses.  There 
is  peritonitis  of  the  diffuse  variety.  Pleuritis,  meningitis,  and  brain 
abscess  may  result.  There  may  be  abscess  in  the  skin  and  also  in 
the  joints,  the  whole  picture  being  that  of  pyaemia.  In  some  cases 
the  symptoms  resemble  those  of  peritonitis  complicated  with  icterus ; 
the  respirations  are  shallow,  the  abdomen  tense,  and  the  thighs  are 
flexed  on  the  abdomen. 

Treatment.— It  is  hardly  necessary  to  say  that  prophylaxis  is  in 
all  septic  affections  the  mainstay  of  the  physician.  Once  inaugu- 
rated, infective  processes  in  newborn  infants  are  progressive.  In 
cases  of  the  umbilical  type  I  have  advised  laying  open  the  structures 
passing  from  the  umbilicus  to  the  bladder,  curetting  the  sinus  thus 
formed,  and  inducing  healing  from  the  bottom.  Recovery  has  fol- 
lowed in  a  few  exceptional  cases.  The  operation  should  be  per- 
formed before  general  infection  has  occurred.  Van  Arsdale  operated 
on  one  of  these  cases  for  me  and  obtained  an  apparent  recovery — 
that  is  to  say,  the  sinus  leading  from  the  umbilicus  healed  and  there 
were  no  symptoms  for  weeks  after  the  operation. 

In  some  recorded  cases  the  liver  has  been  incised  for  abscesses. 
One  case  occurred  in  an  infant  three  months  of  age,  the  subject  of 
umbilical  phlebitis.  The  results  obtained  with  antistreptococcic  sera 
have  not  been  encouraging. 

Hemorrhage  from  the  Umbilicus  (Omphalorrhagia)-  —  Hemor- 
rhage from  the  umbilicus  may  occur  (a)  from  the  vessels  of  the  umbil- 
ical cord  or  (h)  from  the  umbilical  wound  itself  (parenchymatous). 

Hemorrhage  from  the  vessels  of  the  cord  may  occur  if  the  ligature 
has  not  been  properly  applied;  but  faulty  ligation  alone  will  not 
account  for  the  hemorrhage  in  all  cases.  Runge  states  that  if  the 
cord  is  cut  ten  or  fifteen  minutes  after  a  healthy  infant  has  cried 
lustily  there  will  be  little  hemorrhage — certainly  not  one  threatening 
life.  The  diminution  of  arterial  pressure  in  the  bloodvessels  at 
this  point,  due  to  the  establishment  of  the  pulmonic  circulation  and 
the  natural  contractility  of  the  vessels,  prevents  hemorrhage.  The 
fact  that  infants  among  savage  peoples  and  the  young  of  lower  animals 
do  not  bleed  to  death,  although  the  cord  is  not  ligated,  but  simply 
divided,   is  thus   explained.     If  an  infant,   therefore,   bleeds   after 


212  DISEASES  OF  THE  NEWBORN. 

ligation  of  the  cord,  the  reason  must  be  sought  in  some  physiological 
or  anatomical  defect  of  the  bloodvessels.  We  possess  no  data  which 
would  explain  the  absence  of  normal  arterial  contraction  in  the  ves- 
sels of  the  cord.  Inasmuch  as  this  condition  may  be  present  during 
the  first  days  after  birth,  great  care  should  be  taken  that  the  ligature 
is  properly  applied.  Caution  should  especially  be  exercised  with  pre- 
mature infants,  in  whom  the  bloodvessels  are  in  an  embryonic  state. 

After  the  separation  of  the  umbilical  stump  a  few  drops  of  blood 
may  be  seen  on  the  wound  from  time  to  time.  This  is  of  no  moment. 
The  wound  should  be  dressed  with  a  salicylic  powder  and  amylum 
(1:5),  and  covered  with  a  dry  dressing. 

Idiopathic  Hemorrhage  from  the  Umbilicus  {True  Omphalor- 
rhagia).— Occurrence.. — Winckel,  quoted  by  Runge,  has  seen  only  1 
case  in  5000  births  of  true  idiopathic  hemorrhage  from  the  umbil- 
icus. Males  are  more  frequently  attacked  than  females.  I  have  seen 
a  few  cases  of  this  affection. 

Etiology. — According  to  Grandidier,  infants  apparently  healthy 
and  strong  are  for  the  most  part  affected.  This  form  of  hemorrhage 
occurs  also  in  infants  suffering  from  congenital  syphilis,  septic  infec- 
tions, or  the  acute  fatty  degeneration  of  the  newborn.  In  some  forms 
of  congenital  syphilis  there  may  be  hemorrhages  into  the  skin,  stomach, 
intestine,  and  internal  organs.  In  these  cases  it  is  not  surprising 
that  hemorrhage  should  also  occur  from  the  umbilicus.  Icterus,  due 
to  syphilitic  affections  of  the  liver  and  lung,  may  be  present. 

In  51  cases  of  hemorrhage  from  the  umbilicus,  Epstein  found 
pronounced  septicsemia  in  24.  The  affection  is  especially  prevalent 
under  unhygienic  conditions  and  in  foundling  asylums.  Klebs,  Ep- 
pinger,  Cohnheim,  and  Weigert  have  described  cases  of  hemorrhage 
in  which  micro-organisms  of  various  kinds  were  found  in  the  blood 
and  in  the  hemorrhagic  areas.  Bacterial  colonies  were  found  in  the 
arterial  thrombi  and  in  the  lungs  and  kidneys. 

The  occurrence  of  hemorrhage  from  the  umbilicus  in  Buhl's  dis- 
ease is  elsewhere  described. 

Symptoms. — About  the  fifth  day  after  birth,  immediately  follow- 
ing separation  of  the  umbilical  stump,  blood  is  seen  to  ooze  from  the 
umbilicus.  It  does  not  appear  to  issue  from  any  particular  vessel, 
but  oozes  from  the  whole  umbilical  wound,  as  from  a  sponge.  The 
flow  may  be  slight  at  first  and  then  profuse,  or  may  be  profuse  from 
the  outset.  Pressure  upon  the  wound  may  cause  the  hemorrhage  to 
cease,  but  the  flow  begins  when  pressure  is  withdrawn.  In  some 
cases  the  infants  have  enjoyed  excellent  health  previous  to  the  hemor- 
rhage. In  others  there  may  have  been  a  slight  icterus  or  diarrhoea. 
However  this  may  be,  after  bleeding  commences  cyanosis  and  icterus 
of  the  general  surface  appear,  giving  the  skin  a  peculiar  bronzed 


DISEASES  OF  THE  UMBILICUS.  2l3 

appearance.  There  are  hemorrhages  from  the  stomach  and  gnt. 
Ecchymoses  appear  in  the  vicinity  of  the  umbilicns  and  on  other  parts 
of  the  trunk.  (Edema  of  the  ankle-joints  and  wrists  supervenes. 
The  hemorrhage  from  the  umbilicus  is  the  most  characteristic  symp- 
tom, and  cannot  be  controlled  by  any  means.  The  blood  coagulates 
very  slowly. 

Duration.' — The  disease  lasts  from  a  few  hours  to  two  weeks. 
Grandidier's  statistics  give  a  mortality  of  83  per  cent.  Death  ensues 
in  collapse,  with  convulsions. 

Treatment. — Treatment  is  directed  to  controlling  the  hemorrhage 
by  pressure  or  by  transfixing  the  umbilical  wound.  From  a  study  of 
the  pathogeny  of  this  affection,  it  is  evident  that  no  form  of  local 
treatment  can  be  successful. 

Umbilical  Herniae. — In  newly  born  infants  we  distinguish  two 
varieties  of  hernia  at  the  umbilicus. 

The  first  form  is  of  serious  character.  It  is  really  a  hernia  of 
the  umbilical  cord  (hernia  funiculi  umbilicalis).  The  condition  is 
due  to  an  arrest  of  development,  as  a  result  of  which  there  is  a  true 
defect  in  the  abdominal  wall  at  the  situation  of  the  umbilicus.  The 
gut  prolapses  and  is  covered  by  the  amnion  of  the  cord  and  Wharton's 
jelly,  beneath  which  is  the  peritoneum.  The  latter  is  immediately 
over  the  gut.  Many  of  the  infants  thus  affected  are  premature.  In 
others  deformities  are  present.  The  hernia  is  a  round  or  oval  tumor 
of  the  size  of  a  walnut  or  an  orange,  located  in  the  region  of  the 
umbilicus,  and  is  continuous  with  the  cord.  The  sac  of  the  hernia 
is  formed  by  the  peritoneum  and  amnion.  The  abdominal  walls 
form  the  border  of  the  sac.  Gut,  liver,  spleen,  kidney,  or  pancreas 
may  be  found  in  the  sac. 

If  treatment  is  not  instituted  at  the  time  of  separation  of  the 
cord,  and  the  hernia  is  large,  ulceration,  gangrene,  or  septic  peri- 
tonitis in  the  sac  contents  may  result. 
.  The  second  and  most  common  form  of  hernia  in  this  region  is 
due  to  a  weakness  at  the  point  of  insertion  of  the  cord.  The  hernia 
becomes  apparent  a  few  weeks  after  birth,  when  the  cord  has  com- 
pletly  cicatrized.  It  is  then  noticed  that  when  the  infant  cries  there 
is  a  protusion  at  this  point.  The  protrusion  may  be  small  or  large, 
and  is  covered  by  the  thin  cicatrized  skin.  The  hernia  may  be 
central  or  at  one  side,  or  a  little  above  or  below  the  centre  of  the 
umbilical  ring. 

Treatment. — The  treatment  of  the  first  form  is  purely  surgical, 
and  consists  in  splitting  open  the  sac  and  sewing  the  abdominal 
parietes  in  apposition.  The  treatment  of  the  second  form  is  simple. 
As  a  prophylactic  measure  a  small  pad  should  be  placed  on  the 
abdomen,  underneath  the  binder,  and  should  be  worn  for  some  time 


214  DISEASES  OF  THE  NEWBORN. 

after  the  stuiap  is  healed,  in  order  that  there  may  be  no  protrusion 
of  the  wall  and  gut  during  crying  spells.  If  the  hernia  has  taken 
place,  a  firm  pad,  made  by  enclosing  a  piece  of  thick  cardboard,  one 
and  a  half  inches  in  diameter,  in  a  piece  of  linen,  should  be  applied, 
and  supported  by  rubber  plaster.  Another  method  is  to  reduce  the 
hernia,  fold  it  inward  by  means  of  the  apposing  abdominal  walls,  and 
secure  the  walls  thus  brought  together  with  plaster.  The  plaster 
should  be  renewed  every  three  days  lest  ulceration  of  the  skin  result. 
As  soon  as  the  muscles  of  the  abdomen  gain  strength  and  the  infant 
is  able  to  stand,  the  opening  at  the  umbilicus  closes  and  the  hernia 
remains  reduced. 

PERITONITIS   OF   THE   NEWBORN. 

Occurrence. — This  affection  may  occur  from  the  first  to  the  seventh 
day  after  birth,  and  sets  in,  as  a  rule,  with  vomiting,  pain,  as  evi- 
denced by  crying;  diarrhoea,  tympanitis,  disappearance  of  the  liver 
dulness.  dulness  in  flanks,  showing  the  presence  of  fluid  in  the  abdom- 
inal cavity.  Peritoneal  fluid  may  collect  in  the  pelvis  and  appear 
in  the  scrotum,  simulating  hydrocele.  In  such  a  case  the  right  side 
of  the  scrotum  is  mostly  affected,  and  there  is  accompanying  oedema. 
The  temperature  may  be  as  high  as  40°  C.  (104°  F.).  There  are 
restlessness,  emaciation,  facies.  and  death  supervenes  in  from  four 
to  five  days.  Infection  is  not  always  limited  to  the  peritoneum: 
there  may  be  blennorrhcpa.  phlegmon,  erysipelas,  hemorrhages,  or 
gangrene  of  the  umbilicus,  and  with  these  we  may  have  arteritis, 
pleurisy,  and  visceral  abscesses.  Peritonitis  of  the  newborn  may 
originate  at  the  umbilicus,  which  is  a  port  of  entry  for  bacteria. 

Prognosis. — The  prognosis  of  these  cases  is  grave;  most  of  them 
result  fatally. 

TETANUS    OF    THE    NEWBORN    INFANT. 

(Trismus  Neonatorum.) 

Tetanus  of  the  newborn  is  an  acute  infectious  disease  or  intoxi- 
cation, strictly  speaking,  characterized  by  trismus  and  tonic  muscular 
spasms,  rarely  convulsions. 

Etiology.- — Tetanus  of  the  newborn  infant  is  in  the  majority  of 
cases  due  to  infection  of  the  umbilical  wound  by  the  tetanus  bacillus. 
The  bacillus  is  conveyed  to  the  wound  by  means  of  unclean  hands, 
bandages,  or  filth  of  any  kind.  As  a  result  of  the  growth  of  the 
bacillus  ptomaines  are  formed,  enter  the  circulation,  and  are  widely 
distributed  throughout  the  body.  Infection  may  occur  at  the  time 
of  the  ligation  of  the  cord  or  during  the  separation  of  the  stump. 


TETANUS  OF  THE  NEWBORN  INFANT.  215 

In  8  per  cent,  of  the  cases  the  disease  manifests  itself  immediately 
after  birth  (Hartigan). 

Hartigan's  assertion  that  in  most  cases  symptoms  appear  from 
the  first  to  the  fifth  day  after  the  separation  of  the  stump  of  the 
cord  is  incorrect.  As  a  rule,  the  onset  is  from  the  fifth  to  the  twelfth 
day  afterbirth  (Runge).  It  is  rare  after  the  third  week.  The  incu- 
bation period  in  the  human  subject  varies  from  one  to  sixty  days. 
In  animals  which  have  been  the  subject  of  experiment  the  period  of 
incubation  has  been  but  a  few  hours.  Subdural  injections  in  animals 
have  given  the  shortest  incubation  period. 

Tetanus  is  common  in  districts  in  which  uncleanliness  in  the 
methods  of  treating  the  umbilical  cord  prevails.  It  is  endemic  in  the 
Faroe  Islands,  and  is  common  in  the  Hebrides,  Cuba,  and  Jamaica. 
ifsTegroes,  especially,  are  prone  to  the  malady,  on  account  of  their  lack 
of  cleanliness  in  treating  the  cord.  Tetanus  of  the  newborn  infant 
has  been  demonstrated  by  Beumer  and  Peiper  to  be  identical  with 
tetanus  in  the  adult. 

Morbid  Anatomy. — Beck  has  described  two  cases  of  tetanus  with 
swelling  of  the  motor  ganglion-cells,  and  degeneration  of  the  periph- 
eral portion  of  the  cells  with  atrophy.  There  are  also  changes  in 
the  chromatin  of  the  cell.  Congestion  and  hemorrhages  in  the  brain 
and  cord,  serous  exudates  in  the  cord,  and  congestion  of  the  internal 
organs,  due  to  convulsions,  are  present. 

Ssmiptoms. — There  is  a  premonitory  period  of  restlessness.  The 
infants  awake  abruptly  from  sleep.  They  nurse  badly,  let  go  of  the 
nipple  suddenly,  and  cry.  The  peculiarity  of  the  disease  in  infants 
is  the  predominance  of  trismus,  with  which  the  attack  begins.  The 
lower  jaw  becomes  rigid  and  fixed  at  a  distance  of  a  few  lines  from 
the  upper  jaw.  It  is  impossible  to  introduce  the  nipple  between  the 
teeth.  At  first  there  is  a  tremulous  contraction  of  the  muscles  of 
the  lower  jaw.  It  is  then  noticed  that  the  infant  is  unable  to  open 
the  jaw,  and  on  slight  irritation,  either  with  the  fingers  or  with  the 
breast  nipples  during  nursing,  the  lips  become  puckered  into  the 
position  of  playing  the  flute,  and  the  jaw  is  contracted  and  fixed. 

The  muscles  of  deglutition  become  affected,  so  that  swallowing 
is  impossible,  and  all  fiuid  introduced  is  returned  or  rejected.  The 
forehead  is  wrinkled,  and  the  palpebral  fissure  diminished.  The 
condition  of  rigid  spasm  spreads  to  the  other  muscles  of  the  body, 
such  as  those  of  the  neck,  back,  and  extremities,  and  there  is  opis- 
thotonos. At  intervals  this  spasm  relaxes.  At  the  outset,  during 
the  intervals  between  the  attacks  of  rigidity,  the  body  is  lax ;  during 
such  intervals  the  unfortunates  may  obtain  some  rest  and  take  nour- 
ishment. These  intervals  become  shorter  and  shorter,  until  finally 
the  body  is  in  a  state  of  constant  rigidity,  resting  on  the  heels  and 


216  DISEASES  OF  THE  NEWBORN. 

the  back  of  the  head.  The  muscular  spasm  is  a  tonic  one,  called 
forth  by  the  least  irritation,  or  by  sound  or  a  moving  body  in  the 
room,  or  even  by  a  draft  of  air.  Dyspnoea  with  resultant  cyanosis 
is  present  when  the  muscles  of  respiration  become  affected.  Deglu- 
tition is  impossible.  There  is  no  cry,  on  account  of  spasm  of  the 
laryngeal  muscles.  The  temperature  may  reach  41°  C.  (106°  F.). 
In  protracted  cases  it  may  be  normal.  The  pulse  is  accelerated. 
The  urine  and  fseces  are  passed  involuntarily.  There  is  albumin  in 
the  urine.  The  respirations  are  superficial.  The  heart  action  is 
increased;  the  pulse  may  be  200.  During  a  contracture  the  skin  is 
dark  red  and  cyanotic.  Icterus  may  be  present.  The  face  is  fixed 
in  expression  and  oedematous. 

Duration. — The  disease  lasts  from  a  few  days  to  three  weeks. 
Death  may  ensue  in  from  one  to  six  days  from  asphyxia  or  exhaus- 
tion. In  rare  cases  the  attacks  become  less  and  less  frequent,  and 
finally  cease.  Fracture  of  the  bones  and  rupture  of  the  muscles  are 
among  the  complications. 

Diagnosis. — The  diagnosis  offers  no  difficulties.  The  sudden  onset 
and  rigid  contraction  of  the  muscles  of  mastication  and  deglutition, 
the  intensification  of  the  contractures  by  the  least  irritation,  the  opis- 
thotonos with  intervals  of  relaxation  and  contraction,  the  tempera- 
ture— all  tend  to  aid  in  the  diagnosis.  The  only  question  which  can 
arise  is  that  relative  to  the  differentiation  of  tetanus  from  contractures 
with  paralysis  due  to  traumatism  after  birth.  In  the  latter  case, 
however,  there  will  be  corresponding  pareses,  such  as  are  seen  in 
the  face. 

Again,  tetanus  may  be  confounded  with  cerebrospinal  meningitis 
in  the  newborn,  due  to  infection  with  staphylococci,  streptococci,  or 
meningococci.  In  meningitis  there  is  no  trismus  or  tetanic  spasms, 
though  there  may  be  rigidity  of  the  muscles  of  the  neck  and  back. 
In  doubtful  cases  lumbar  puncture  will  reveal  micro-organisms  of 
meningitis  in  the  cerebrospinal  fluid. 

Prognosis. — The  prognosis  is  grave.  Baginsky  lost  all  of  his  cases 
in  newborn  infants,  while  Escherich,  Soltman,  and  Monti  report 
recoveries.  Cases  which  occur  late,  after  separation  of  the  cord, 
give  a  better  prognosis  (Papiewski).  Patients  die  of  exhaustion, 
as  a  result  of  sleeplessness,  lack  of  food,  and  general  strain  on  the 
nervous  system. 

Treatment. — Prophylaxis  is  of  the  utmost  importance  in  this  as 
in  other  diseases  of  the  newborn  infant.  Cleanliness  in  handling  the 
cord  is  of  the  first  importance.  Escherich  cauterizes  the  stump  of 
the  cord,  to  destroy  any  bacilli  of  tetanus  which  may  be  present. 
On  the  appearance  of  trismus,  the  treatment  is  first  directed  to  the 
relief  of  the  tonic  spasms.     Chlorate  hydrate  in  1-grain  (0.06)  doses 


ICTERUS  IN  THE  NEWBORN  INFANT.  217 

every  few  hours,  by  mouth,  or  by  the  rectum,  is  a  very  useful  drug. 
Calabar  bean  in  the  form  of  the  extract  is  recommended  by  Monti, 
who  gives  K20  grain  (0.0005)  subcutaneously,  repeated  until  the 
desired  effect  is  obtained.  Cannabis  indica,  ^  grain  (0.03)  every 
two  hours,  is  also  given  internally.  Curare  has  been  used  but  little 
with  the  newborn  infant.  Of  the  other  remedies,  bromide  of  potas- 
sium and  trionol  have  little  effect. 

Aside  from  the  treatment  of  tetanus  in  the  newborn  by  means  of 
drugs,  the  treatment  by  means  of  tetanus  antitoxin  should  be  resorted 
to  in  every  case,  in  spite  of  the  fact  that  failures  have  been  recorded 
by  Heubner,  Leyden,  and  Blumenthal.  We  should  inject  antitoxin 
as  soon  as  symptoms  appear,  inasmuch  as  favorable  cases  have  been 
reported  by  Tizzone,  Behring,  Engelmann,  Kohler,  and  others.  The 
antitoxin  is  given  by  means  of  lumbar  puncture.  A  puncture  is 
made  in  the  ordinary  way  in  the  lumbar  region,  as  elsewhere  de- 
scribed. Five  cubic  centimetres  of  cerebrospinal  fluid  is  allowed  to 
flow  off.  The  Quincke  funnel  is  then  attached  to  the  puncture-needle 
and  5  c.c.  of  antitoxin  are  introduced.  Another  method  is  to  inject 
half  of  the  serum  by  lumbar  puncture  and  the  other  half  sub- 
cutaneously. 

The  use  of  the  tetanus  antitoxins  has  not  given  satisfactory  results, 
probably  owing  to  the  fact  that  tetanus  is  a  symptom  of  advanced 
toxaemia  of  the  nervous  system.  In  such  a  condition  the  action  of 
any  antitoxin  would  be  exerted  too  late  to  give  permanent  benefit. 
These  patients  being  unable  to  swallow  must  be  fed  per  rectum  until 
the  acute  symptoms  have  subsided  and  deglutition  is  possible. 

ICTERUS  IN   THE   NEWBORN  INFANT. 

The  majority  of  newborn  infants  are  icteric.  Icterus  in  the 
othervdse  normal  newborn  infant  should  be  differentiated  from  that 
due  to  sepsis,  syphilis  of  the  liver,  cirrhosis  of  the  liver,  stenosis  of 
the  common  bile-duct,  and  yellow  atrophy  of  the  liver.  Acute  yellow 
atrophy  of  the  liver  in  the  mother  during  pregnancy  may  produce  an 
icteric  condition  in  the  newborn  infant. 

Icterus  Neonatorum, — An  opportunity  is  rarely  afforded  to  in- 
spect postmortem  the  viscera  of  cases  of  icterus  neonatorum,  since 
recovery  ensues  in  the  majority  of  cases.  In  cases  which  have  come 
to  the  autopsy  table,  all  the  internal  organs,  including  the  bones  and 
cartilages,  were  icteric.  The  spleen  and  kidneys  were  but  little 
affected,  even  in  severe  forms,  by  the  general  icteric  discoloration. 
In  rare  cases  the  liver  was  microscopically  jaundiced.  The  intima 
of  the  arteries,  the  fluids  in  the  serous  cavities,  the  pericardial  fluid, 
and  the  subcutaneous  and  intermuscular  connective  tissue  have  been 


218  DISEASES  OF  THE  NEWBOBN. 

found  to  contain  bile-pigment  and  biliary  acids  (Birch-Hirschfeld). 
The  contents  of  the  gut  were  normal.  The  kidneys  contained  uric 
acid  infarctions. 

Etiology. — Icterus  neonatorum  is  as  frequent  in  institutions  as 
in  private  practice.  It  is  more  common  among  boys  (Kehrer).  It 
is  seen  in  premature  weak  infants,  and  in  those  whose  birth  has 
been  attended  by  complications.  The  disease  is  now  traced  to  both 
a  haematogenous  and  a  hepatogenous  source.  There  are  certain 
processes  in  the  blood  which  also  involve  the  functions  of  the  liver. 
According  to  Hofmeier  and  Silbermann  there  is  a  disintegration  of 
red  blood-cells  in  the  circulation.  These  disintegrated  red  blood- 
cells  are  converted  by  the  liver  cell  into  biliary  pigment ;  the  solids 
of  the  bile  are  increased,  as  is  also  the  gross  quantity  of  bile  (Min- 
kowski, IsTaunyn,  Stadelmann).  It  is  not  known,  however,  how 
this  increase  of  bile-pigment  gains  access  to  the  circulation.  One 
theory  (Silbermann)  is  that  with  the  processes  described  above  cer- 
tain ferments  are  set  free  which  cause  circulatory  disturbances  in  the 
liver.  Stasis  results  in  the  bloodvessels,  with  consequent  pressure 
on  the  biliary  ducts.     Resorption  of  bile  thus  follows. 

Symptoms.- — Fully  80  per  cent,  of  all  newborn  infants  become 
jaundiced  shortly  after  birth  (Eunge).  The  jaundice  appears  on  the 
second  or  third  day  after  birth.  .  The  icterus  may  be  slight  and 
involve  only  the  face,  breast,  and  back,  or  may  be  severe  and  extend 
over  the  whole  trunk.  In  severe  forms  icterus  of  the  conjunctivae 
is  present.  In  this  feature  icterus  neonatorum  differs  from  ordinary 
catarrhal  icterus,  in  which  icterus  of  the  conjunctivae  is  the  first 
symptom  before  the  skin  is  perceptibly  tinged.  The  conjunctivas  are 
last  to  be  tinged  in  the  jaundice  of  the  newborn.  Infants  suffering 
from  icterus,  though  in  an  apparently  normal  condition,  do  not 
increase  in  weight  as  normal  infants  do,  and  may  even  lose  ground. 
When  they  recover  lost  weight,  they  do  so  slowly. 

The  urine  is  brownish  at  times  and  contains  biliary  pigment  and 
acids  (Cruse  Hofmeier). 

Treatment. — Icterus  neonatorum,  if  untreated,  disappears  in  three 
or  four  days  in  mild  cases ;  severe  cases  are  more  protracted.  Neither 
form  needs  special  treatment. 

Icterus  Gravis  of  the  Newborn. — This  is  a  form  of  icterus  oc- 
curring in  the  newborn.  It  is  characterized  by  its  severity  and  the 
intensity  of  the  icterus,  accompanied  as  it  is  by  hemolysis  and  pig- 
mentation of  the  mucous  surface ;  it  is  generally  fatal.  It  has  been 
described  by  Benecke  and  Pfannestiel;  it  occurs  in  families:  one 
author  having  seen  nine  cases  in  the  same  family.  Autopsy  shows 
affections  of  the  serous  cavities ;  punctate  hemorrhages  in  the  internal 
organs;  increase  in  size  of  the  liver  and  spleen  and  general  intense 


MELMNA  NEONATORUM.  219 

icterus.  In  cases  so  far  published,  the  parents  gave  no  syphilitic 
history.  The  authors  mentioned  do  not  consider  it  identical  with 
Buhl's  or  Winckel's  disease,  or  dependent  on  any  septic  infection, 
but  rather  classify  it  as  a  dyscrasia. 

HEMORRHAGES  IN  THE  NEWBORN. 

Hemorrhages  in  the  newborn  are  frequent  as  a  result  of  infec- 
tion. These  hemorrhages  may  accompany  ordinary  septic  infection 
and  form  part  of  the  symptomatology  of  sepsis ;  or  they  may  assume 
a  characteristic  symptom-complex,  and,  as  such,  make  up  a  definite 
picture  corresponding  to  what  has  been  formerly  described,  and  still 
retained  in  the  text-books  for  the  sake  of  lucidity,  as  melsena  neona- 
torum, Winckel's  disease,  and  Buhl's  disease.  Hemorrhages  in  the 
newborn  may  occur  from  the  nose,  the  mouth,  the  conjunctiva,  the 
umbilical  wound,  the  stomach,  the  intestines,  the  vagina,  the  skin, 
and  into  most  of  the  internal  organs.  The  causes  of  such  hemor- 
rhages are  either  congenital  hasmophilia,  or  an  underlying  dyscrasia, 
such  as  syphilis,  or  septic  infection.  A  congenital  haemophilia  is 
rare  and  plays  but  a  minor  role  in  the  causation  of  hemorrhages  in 
the  newborn.  Grandidier  records  only  12  of  575  cases  of  hemor- 
rhage caused  by  hsemophilia.  In  syphilitic  infants  hemorrhages 
may  occur  from  two  to  three  days  after  birth,  either  underneath  the 
skin,  from  fissures  in  the  skin,  from  the  stomach,  the  intestines,  or 
the  internal  organs.  Some  contend  that  in  these  syphilitic  infants, 
in  addition  possibly  to  some  infection,  there  is  a  change  in  the 
arteries;  others  deny  that  such  changes  exist,  and  contend  that  the 
arterial  changes  described  by  Mracek  are  found  in  the  normal  infant 
(Fischl).  Inasmuch  as  these  syphilitic  infants  come  into  the  world  as 
weaklings,  and  are  on  this  account  susceptible  to  infection,  it  is  more 
rational  to  suppose  that  if  hemorrhages  occur  they  are  the  result  ol 
septic  infection.  Sepsis,  therefore,  is  the  main  factor  in  the  causa- 
tion of  all  hemorrhages  in  the  newborn.  The  clinical  symptoms  oi 
these  hemorrhages  and  accompanying  constitutional  disturbances  will 
be  described  under  the  sections  devoted  to  them.  Some  forms  of 
hemorrhage  have  been  considered  in  the  sections  which  treat  of  sepsis 
of  the  newborn,  diseases  and  infection  of  the  umbilical  wound,  and 
structures.  The  remaining  forms  will  now  be  described,  and  for  the 
sake  of  lucidity  the  early  nomenclature  is  still  retained. 

MEL-aiNA   NEONATORUM. 

Etiology.- — This  is  a  disease  of  the  newborn  characterized  by  a 
discharge  of  blood  from  the  rectum  and  by  vomiting  of  blood.  It  is 
a  rare  affection,  occurring  about  once  in  1000  births  (Kling,  Genrich, 
Runge).     The  hemorrhages  occur  in  two  distinct  conditions: 


220  DISEASES  OF  THE  NEWBOBN. 

(a)  As  a  symptom,  of  a  constitutional  dyscrasia.  This  condition 
has  been  treated  of  under  the  headings  of  Hemorrhagic  Congenital 
Syphilis,  Sepsis,  and  the  Acute  Fatty  Degeneration  of  the  Newborn. 
Runge  has  shown  that  not  only  may  the  diseases  named  cause  melsena, 
but  that  any  of  the  infectious  diseases  of  the  newborn  may  give  rise 
to  this  condition. 

(&)  The  second  condition  in  which  melsena  occurs  is  that  in  which, 
as  Landau,  in  his  monograph  on  this  disease  has  shown,  local  lesions, 
such  as  erosions  and  ulcerations  resembling  ulcus  ventriculi,  exist  in 
the  stomach  and  gut  of  the  newborn  infant.  Hecker,  Spiegelberg, 
and  others  have  also  described  these  ulcers  of  the  stomach  which 
produce  the  symptoms  of  melsena.  Landau  attributes  the  ulcers  to 
embolism  resulting  from  a  thrombus  of  the  umbilical  vein  or  the 
ductus  Botalli.  Embolism  in  any  artery  of  the  mucous  membrane 
of  the  stomach  gives  rise  to  necrosis  and  erosion,  with  the  opening 
up  of  some  arterial  branch.  Ingenious  as  this  theory  is,  it  is  not 
accepted  unreservedly  by  all,  although  Landau  has  proved  the  pres- 
ence of  emboli  in  the  vicinity  of  stomach  ulcerations.  Another 
theory  ascribes  the  ulcerations  to  hypersemia  of  the  mucous  membrane 
in  asphyxia  and  traumatism. 

Melsena  neonatorum  can  be  caused  not  only  by  a  coccal  sepsis,  but 
by  a  bacillary  infection,  as  shown  by  Gartner,  who  found  a  bacillus 
in  the  fseces,  and  in  the  hemorrhages  from  the  various  organs  and 
peritoneum.  In  other  cases  it  is  very  probable  other  microorganisms 
will  be  found  to  have  caused  the  sepsis. 

In  addition  there  are  cases  in  which  no  cause  can  be  found  to 
account  for  the  symptoms. 

Morbid  Anatomy. — Postmortem  examination  shows  the  gastro- 
enteric tract  to  be  filled  with  dark  hemorrhagic  masses.  The  mucous 
membrane  may  be  normal,  the  seat  of  erosions  of  greater  or  lesser 
extent,  or  there  may  be  hemorrhagic  areas  scattered  throughout  the 
gut.  These  may  be  confined  to  the  stomach  or  duodenum.  There 
may  be  true  ulcers  of  the  stomach  measuring  -^  to  2  cm.  in  diameter, 
resembling  those  seen  in  the  adult  (Winckel).  In  some  cases  the 
thrombosed  or  eroded  vessel  is  found  in  the  floor  of  the  ulcer  or  in 
its  vicinity.  All  the  organs  are  ansemic,  and  if  syphilis  or  some 
other  general  disease  exists  there  are  the  changes  found  in  these 
conditions. 

Symptoms.- — From  two  to  four  days  after  birth  it  is  noticed  that 
the  infant  is  somnolent  or  restless ;  there  may  be  hemorrhagic  stools 
or  vomiting  of  bloody  masses,  or  both  these  symptoms  may  be  present 
at  the  same  time.  The  principal  symptom,  however,  is  the  bloody 
stools.  These  are  at  first  mingled  with  meconium,  and  later  become 
frequent    and    profuse.      The    vomited    matter    consists    of    mucus 


ACUTE  FATTY  DEGENERATION  OF  THE  NEWBORN.  221 

streaked  with  blood,  or  masses  of  blood  of  brownish  color.  The 
amount  of  blood  lost  by  the  bowel  within  twenty-four  hours  may  be 
quite  great.  Under  these  conditions  death  ensues  within  a  period 
of  from  twelve  to  twenty-four  hours,  with  all  the  symptoms  of  acute 
anaemia.  In  other  cases  there  may  be  a  cessation  of  the  intestinal 
hemorrhage  for  from  twenty-four  to  forty-eight  hours,  but  recovery 
does  not  always  take  place,  and  sudden  death  from  a  severe  hemor- 
rhage may  occur  at  any  time. 

Prognosis. — The  prognosis  is  grave.  Sixty  per  cent,  of  the  infants 
affected  die.  The  outlook  is  more  serious  in  conditions  of  sepsis, 
syphilis,  and  acute  fatty  degeneration  than  in  melsena  due  to  ulcer  of 
the  stomach  or  duodenum. 

Diagnosis. — We  must  differentiate  this  disease,  which  is  called 
true  melsena,  from  the  so-called  spurious  form,  in  which  the  infant 
simply  passes  blood  swallowed  with  the  food.  This  spurious  form 
may  occur  if  the  breast  nipple  is  fissured  or  if  there  is  a  fissure  of 
the  anus.  In  other  cases  blood  from  the  nose  or  mouth  of  the  infant 
may  be  swallowed.  Hemorrhages  of  this  kind  may  occur  as  part  of 
a  general  septic  infection.  In  many  cases  there  may  be,  with  other 
hemorrhages,  icterus,  cyanosis,  oedema,  pointing  to  some  general  dis- 
ease. Sensitiveness  in  the  region  of  the  stomach  points  to  ulcera- 
tion of  this  organ. 

Treatment. — The  hemorrhages  should  be  controlled  by  the  appli- 
cation of  a  cold  coil  to  the  epigastrium  and  the  administration  of  cold 
drinks.  Henoch  recommends  a  drop  of  liquor  ferri  sesquichloridi 
every  hour  in  barley-water.  Ergotin  is  given  in  doses  of  ^  to  f 
grain  internally  or  subcutaneously.  Suprarenal  extract  has  been 
administered  in  some  cases  which  have  recovered  and  may  be  tried. 
In  a  case  coming  under  my  care  adrenalin  was  of  no  avail.  Enemata 
are  not  advisable.  The  heart  is  stimulated  with  strychnine,  digitalis, 
camphor,  or  ether. 

ACUTE    FATTY    DEGENERATION    OF    THE    NEWBORN. 

{Buhl's  Disease.) 

This  disease,  first  described  in  1861  by  Buhl,  is  an  acute  paren- 
chymatous fatty  degeneration  of  the  liver,  kidney,  or  heart,  combined 
with  hemorrhages  into  the  various  organs,  or  from  the  umbilicus, 
intestines,  or  stomach. 

Etiology. — The  disease  occurs  in  the  lower  animals,  especially  in 
sheep.  In  the  human  subject  it  is  a  form  of  septic  infection,  although 
in  Buhl's  cases  the  vessels  of  the  umbilicus  had  a  normal  appearance. 
Septic  infection  may  occur  without  any  appreciable  changes  about 
the  umbilicus  or  elsewhere  on  the  surf  ace  of  the  body  (cryptogenetic). 


222  DISEASES  OF  THE  NEWBORN. 

The  disease  is  very  rare;  many  cases  described  as  omphalitis  and 
hemorrhage  from  the  umbilicus  probably  belong  to  the  category  of 
Buhl's  disease. 

Morbid  Anatomy.- — The  body  is  icteric  or  cyanotic ;  there  is  oedema 
of  the  surface,  and  not  infrequently  hemorrhagic  areas  in  the  skin. 
The  umbilicus  may  be  covered  with  blood,  but  the  vessels  and  wound 
are  otherwise  normal.  Hemorrhages  or  petechise  are  found  in  most 
of  the  internal  organs,  especially  the  pleura,  pericardium,  medias- 
tinal tissue,  muscles,  and  mucous  membranes.  The  heart  is  the  seat 
of  fatty  degeneration,  as  is  also  the  liver,  which  is  enlarged.  The 
spleen  is  enlarged  and  soft.  The  kidneys  are  the  seat  of  fatty  paren- 
chymatous changes.  The  stomach  and  intestines  are  filled  with  blood. 
There  are  hemorrhages  into  the  mucous  membrane  of  the  stomach  and 
intestine.     The  intestinal  villi  are  the  seat  of  fatty  degeneration. 

Symptoms. — The  children  are  born  partially  asphyxiated.  At- 
tempts to  resuscitate  them  are  not  fully  successful.  Some  die  in 
asphyxia,  others  after  a  time  have  bloody  diarrhceal  stools.  At  times 
there  is  vomiting  of  blood,  and  when  the  stump  of  the  cord  separates 
there  is  hemorrhage  from  the  umbilicus.  The  bleeding  from  the 
umbilicus  is  parenchymatous,  and  may  be  so  profuse  as  to  cause  death. 
The  skin  is  at  first  cyanotic,  then  icteric  in  hue.  Large  hemorrhagic 
areas  appear  in  the  skin,  conjunctivse,  and  mucous  membrane  of  the 
mouth,  and  bleeding  may  occur  from  the  ear  and  nose.  Icterus  may 
become  extreme.  At  times  oedema  of  the  surface  appears.  The 
temperature  is  not  raised.  Death  ensues  in  collapse.  The  external 
hemorrhages  and  icterus  are  absent  in  some  cases. 

Diagnosis. — In  the  newborn  infant  this  symptom-complex  is 
unique,  and  must  be  looked  upon  as  a  form  of  sepsis,  either  through 
the  umbilicus  or  through  some  other  avenue.  In  the  newborn  infant 
this  disease  may  be  confounded  with  death  from  asphyxia.  In  all 
cases  of  medico-legal  import  the  organs  should  be  examined  for 
parenchymatous  changes  before  an  opinion  is  given. 

Prognosis. — The  disease  is  fatal. 

Treatment. — The  physician  endeavors  to  bring  the  infant  out  of 
the  state  of  asphyxia.  It  can  be  easily  understood  that  he  is  helpless 
in  the  face  of  the  parenchymatous  hemorrhages  and  degenerations^ 
for  which  there  is  at  present  no  remedy. 

WINCKEL'S   DISEASE. 

(Epidemic  Hcemoglobinuria  of  the  Newborn.) 

This  disease,  first  described  in  the  epidemic  form  by  Winckel,  is 
characterized  by  the  sudden  appearance  of  cyanosis  and  icterus  with 
hsemoglobinuri  a. 


WINCEEL'S  DISEASE.  223 

Etiology. — The  etiology  of  the  affection  is  obscure.  Epstein, 
Strelitz,  and  Baginskj  consider  the  disease  a  form  of  septic  infection. 
Winckel's  cases  were  believed  to  be  due  to  the  use  of  infected  drink- 
ing or  bath,  water.  Birch-Hirschfeld  and  Strelitz  found  streptococci 
in  the  various  organs  and  the  blood.  Kamen,  in  an  epidemic  of  the 
disease,  found  the  colon  bacillus  in  the  capillary  bloodvessels  and 
various  organs. 

Morbid  Anatomy. — Postmortem  examination  reveals  no  disease  of 
the  umbilicus  or  umbilical  vessels.  The  kidneys  are  the  seat  of  cor- 
tical hemorrhages.  The  spleen  is  large  and  hard,  and  filled  vdth 
pigment.  There  are  punctate  hemorrhages  in  almost  all  the  organs, 
especially  in  the  pleura,  pericardium,  and  endocardium.  Hemor- 
rhages are  present  in  the  mucous  membrane  of  the  stomach  and  gut, 
and  underneath  the  liver  capsule.  Peyer's  patches,  solitary  follicles, 
and  mesenteric  glands  are  enlarged.  The  liver,  heart,  and  various 
organs  show  fatty  degeneration.  There  are  bacterial  foci  in  the 
liver  and  kidneys.  The  blood  shows  an  increase  in  the  leucocytes 
and  in  the  free  granules. 

Symptoms. — The  symptoms  in  Winckel's  cases  appear  on  the 
fourth  day  after  birth  in  apparently  healthy  and  well-developed 
infants.  The  average  duration  is  thirty-two  hours.  Some  infants 
succumb  in  nine  hours  after  the  onset  of  symptoms.  Restlessness 
and  cyanosis  are  first  noted.  The  latter  is  general,  affecting  the 
trunk  and  extremities.  Icterus  then  develops,  and  becomes  marked 
within  twenty-four  hours.  The  respiration  and  pulse  are  accel- 
erated; the  temperature  may  be  normal,  38°  C.  (100.5°  F.)  ;  the 
skin  is  cool.  At  times  there  are  vomiting  and  diarrhoea.  The  urine 
is  passed  with  tenesmus,  brownish  in  color,  and  contains  blood-cells, 
hsemoglobin,  renal  epithelium,  granular  casts,  micrococci,  detritus, 
and  ammonium  urate.  Convulsions  close  the  scene.  If  the  skin  is 
cut,  a  brownish  syrupy  fluid  exudes. 

Diagnosis. — Owing  to  the  similarity  of  symptoms,  Winckel's  dis- 
ease may  be  confounded  vnth  Buhl's  disease.  The  former  pursues  a 
very  malignant  course,  and  does  not  present  the  intestinal  and  stomach 
hemorrhages  to  the  same  extent  as  the  latter. 

Runge  and  others  are  inclined  to  believe  that  all  these  hemor- 
rhagic affections  are  due  to  a  common  cause — septic  infection.  The 
hsemoglobinuria  is  simply  a  marked  hemorrhage  into  the  kidney. 
Parenchymatous  fatty  degeneration  of  the  various  organs  is  common 
to  both  affections. 

Prognosis,- — The  prognosis  is  fatal. 

Treatment. — The  treatment  is  that  of  sepsis  of  the  newborn. 


224  -  DISEASES  OF  THE  NEWBOEN. 

SCLEREMA. 

(Sclerema  Neonatorum;  Sclercedema  Neonatorum;  Sclerema  Adiposum.) 

This  peculiar  and  rare  affection  is  apt  to  be  confounded  with 
ordinary  oedema.  There  are  two  forms  of  this  condition:  one  form 
called  scleroedema,  or  oedematous  sclercedema  of  Soltman ;  the  second 
form  is  called  sclerema  adiposum,  or  fat  sclerema. 

Scleroedema  (Soltman). — This  aft'ection  is  not  so  rare  in  institu- 
tions on  the  continent  of  Europe,  although  in  this  country  it  is 
uncommon.  It  is  not  as  common  a  disease  as  fat-sclerema,  which 
will  be  described  later.  It  is  a  disease  of  the  newborn,  and  occurs 
only  in  the  first  days  of  life.  Some  children,  according  to  Dennis, 
Billard,  and  Demme,  are  born  with  the  disease.  In  these  cases  the 
children  are  born  cold,  stiff,  cannot  move,  the  surface  is  swollen, 
oedematous,  tense,  a  gTeat  extent  of  surface  being  involved  in  most 
cases;  and  in  some  cases  even  an  ascites  is  present.  In  some,  how- 
ever, the  feet  are  first  swollen,  then  the  whole  body  becomes  involved 
later  on.  Most  of  the  cases  published  have  been  fatal  in  from  a  few 
hours  to  a  few  days  after  birth.  The  form  seen  after  birth  occurs 
mostly  in  premature  infants,  or  in  the  congenitally  weak  infant,  one 
of  twins  or  triplets,  or  in  infants  with  a  syphilitic  history.  The 
disease  usually  begins  four  days  after  birth,  or  may  appear  as  late 
as  the  tenth  day  or  in  the  third  week.  These  children,  as  stated,  are 
mostly  underweight  and  congenitally  weak. 

Etiology. — The  etiology  of  scleroedema,  or  acute  oedema,  is  still  a 
matter  of  speculation.  Weakness  of  the  heart,  a  beginning  nephritis, 
or  an  infection  of  some  kind,  deficiencies  in  circulation  and  respira- 
tion in  premature  infants,  unhygienic  surroundings— all  have  been 
advanced  to  explain  this  rare  condition.  In  the  secondary  form,  the 
so-called  sclerema  adiposum,  there  is  to  a  certain  extent  a  desiccation 
of  the  subcutaneous  tissues.  Sanger  thinks  that  the  excess  of  pal- 
matin  and  stearin  in  the  subcutaneous  fat  of  the  newborn  infant  may 
account  for  the  peculiar  solidification,  since  the  temperature  is 
reduced,  as  it  is  in  fat-sclerema.  There  are  cases  of  fat-sclerema  in 
which  the  temperature,  as  has  been  stated,  is  elevated.  Such  was 
Barker's  case,  and  I  have  recently  seen  such  a  case,  so  that  the  theory 
of  Sanger  is  scarcely  adequate.  The  cases  of  fat-sclerema  which  I 
have  seen  have  created  in  my  mind  the  impression  of  an  infectious 
condition;  though  this  etiology  is  denied  by  most  investigators. 
Barker  found  streptococci  in  the  internal  fluids  after  death. 

Symptoms. — There  are  no  prodromata,  except  possibly  an  uneasi- 
ness on  the  part  of  the  infant,  or  dryness  and  coldness  of  the  surface. 
The  respirations  are  superficial;  the  temperature,  Avhich  falls  in  most 
infants  after  birth,  does  not  return  to  the  normal.  When  the  symp- 
toms are  fully  developed  they  are  seen  first  in  the  lower  extremities. 


SCLEREMA.  225 

ill  the  calves  of  the  legs  and  the  dorsum  of  the  feet,  spreading  thence 
to  the  thighs  and  involving  the  suprapubic  fat.  Karely  the  eyelids 
and  both  upper  extremities  are  involved. 

The  skin  is  oedematous,  swollen,  and  much  thickened.  In  some 
cases  the  skin  does  not  pit  on  pressure;  in  others  the  pitting  takes 
place,  but  the  skin  rapidly  returns  to  the  primary  condition.  The 
color  of  the  skin  is  either  reddish,  if  the  scleroedema  has  appeared 
before  the  process  of  desquamation  is  complete;  whitish,  if  the 
desquamation  of  the  skin  has  been  completed;  or  cyanotic,  if  the 
infant  is  premature.  As  the  disease  progresses  the  skin  becomes 
more  oedematous,  of  a  yellowish,  transparent  color,  and  in  the  first 
form  the  redness  of  the  skin  disappears.  In  the  cyanotic  form  the 
cyanosis  increases,  the  skin  assumes  a  bluish,  marbled  appearance. 
In  the  worst  forms  the  skin  is  so  tense  that  pitting  by  means  of  pres- 
sure with  the  fingers  does  not  occur,  or  immediately  disappears  when 
the  pressure  is  released.  If  the  skin  is  punctured  with  the  needle, 
there  is  an  escape  of  fluid  or  yellowish  serum.  These  infants  take 
the  breast  badly.  They  sometimes  emit  a  peculiar,  shrill  cry,  due, 
it  is  supposed,  to  oedema  of  the  vocal  cords. 

The  temperature  in  the  mild  forms  may  range  from  34°  to  35° 
C.  (93.2°-95°  F.)  ;  in  severer  forms,  from  30°  to  32°  C.  (86-89.6° 
F.),  but  rarely  as  low  as  in  fat-sclerema,  where  it  may  be  22°  C. 
(71.6°  F.).  A  complicating  pneumonia,  however,  may  cause  a  rise 
of  the  temperature  either  to  the  normal  limit  or  even  as  high  as  41° 
C.  (105.8°  F.).  The  heart  is  weak;  the  pulse  may  have  a  frequency 
as  low  as  sixty  a  minute,  and  in  some  cases  is  not  perceptible  at  the 
wrist.  The  respirations  are  superficial,  labored,  and  slow.  The 
urine  contains  albumin,  sometimes  sugar,  and,  if  the  infant  is  icteric, 
bile  pigment ;  it  may  also  contain  red  blood-cells,  granular  casts,  and 
fatty  epithelium,  and  rarely  leucin.  The  disease  in  most  cases  is 
confined  to  the  lower  extremities,  the  mons  veneris  or  suprapubic  fat, 
and  buttocks  and  lower  part  of  the  back,  but  it  may  spread  around 
to  the  abdomen,  involving  its  lower  part.  It  seldom  occurs  in  patches 
or  small  areas.  If  improvement  occurs,  the  oedema  may  disappear, 
leaving  a  condition  of  the  skin  resembling  fat-sclerema.  Under 
these  conditions  the  skin  is  less  wrinkled  and  oedema  of  the  deeper 
parts  disappears  slowly.  In  fatal  cases  death  supervenes  without 
any  marked  symptoms.  The  infants  simply  fail,  the  pulse  becomes 
slow,  the  respiration  ceases ;  children  die  in  apathy  and  coma. 

Duration  and  Complications. — Congenital  cases  may  die  in  a  few 
hours  ;  the  post-natal  may  linger  from  four  days  to  two  weeks.  Com- 
plications are  rare ;  they  have  nothing  in  common  with  the  primary 
disease,  and  result  as  a  consequence  of  the  reduced  circulation  and 
liability  of  these  infants  to  infection.     Hemorrhages  occur  in  the 

15 


226  '  DISEASES  OF  THE  NEWBOBN. 

lung  and  pleura;  lung  complications  may  occur.  Effusions  have  been 
found  in  the  peritoneum  and  pleura ;  the  latter  especially  in  congen- 
ital cases.  The  skin  may  be  the  seat  of  icterus,  pustules,  ulcers, 
erysipelas,  purpura,  or  gangrene,  especially  if  complicating  sepsis  is 
present.  Decubitus  ulcers,  ecchymoses,  and  finally  pneumonia  may 
occur  as  a  septic  complication. 

Morbid  Anatomy. — So  far  as  the  skin  is  concerned,  the  cedema 
postmortem  is  much  the  same  as  during  life.  The  skin,  muscles, 
and  cellular  tissue,  not  only  of  the  skin,  but  of  the  various  regions, 
such  as  the  mediastinum  and  vocal  cords,  are  involved.  In  fatal 
cases  there  has  been  found  intestinal  catarrh,  affections  of  the  lung, 
such  as  atelectasis;  bronchitis,  bronchopneumonia,  pleurisy,  myocar- 
ditis, fatty  degeneration  of  the  liver,  spleen,  and  kidneys,  hemor- 
rhages into  the  lung  and  tissue  of  the  heart. 

Prognosis. — Clementowsky,  v^ho  has  made  a  close  study  of  this 
disease,  has  recorded  152  cases  with  52  deaths.  The  presence,  there- 
fore, of  this  disease  does  not  exclude  the  possibility  of  a  recovery, 
provided  the  infant  retains  a  certain  amount  of  constitutional  resist- 
ance and  the  disease  is  not  widespread. 

Treatment.- — The  treatment  of  this  form  of  scleroedema  being 
much  the  same  as  that  of  fat  sclerema,  both  will  be  treated  under  a 
common  heading. 

Sclerema  Adiposum  (Fat-sclerema) . — This  condition  is  much 
more  common  than  the  sclercedema  just  described,  and  is  not  a  dis- 
ease confined  entirely  to  the  first  days  of  life,  but  may  occur  up  to 
the  sixth  month  of  infancy.  It  is  doubtful  if  the  disease  occurs  as  a 
congenital  condition.  If  so,  it  is  rare.  The  affection  follows  or 
complicates  exhausting  diseases,  and  is  also  seen  complicating  summer 
diarrhoea,  cholera  infantum,  and  pneumonia.  If  seen  as  a  compli- 
cating condition,  it  is  a  forerunner  of  death.  It  may  be  seen  not 
only  in  bottle-fed,  but  also  in  the  breast-fed  infant,  the  victim  of 
these  affections. 

Symptoms. — The  disease  itself  begins  mostly  in  the  calves  of  the 
legs,  but  not  necessarily  where  the  loose  connective  tissue  exists,  as 
the  scleroedema  does.  The  deeper  parts  are  firm ;  the  skin  is  not  mov- 
able, and  has  a  doughy  feel,  as  though  there  were  nodules  of  fat 
imbedded  in  the  tissues.  Another  place  of  predilection  of  its  appear- 
ance is  in  the  face,  where  it  is  first  seen  affecting  either  the  tip  of 
the  nose  or  the  cheeks.  The  affection  is  symmetrical.  It  appears, 
as  has  been  stated,  in  the  calves,  involves  the  dorsum  of  the  feet, 
spreads  to  the  thighs,  involves  the  buttocks,  especially  the  inner  parts 
of  the  thighs,  may  spread  to  the  upper  extremities,  lastly  involving 
the  face.  The  palms  of  the  hands  or  soles  of  the  feet,  even  in  the 
severest  cases,  remain  free ;  as  also  the  scrotum  and  penis. 


SCLEREMA.  227 

The  skin,  when  the  disease  is  fully  developed,  is  flat,  shining, 
tense,  closely  adherent  to  the  subadjacent  parts,  or  it  may  be  of  a 
yellowish,  whitish,  lardaceons  appearance,  or  may  be  ecchymotic, 
cyanosed,  or  red  in  areas.  When  the  skin  is  palpated  it  has  a  doughy 
feel,  very  much  as  is  seen  in  a  corpse.  The  skin  has  lost  all  its 
original  resiliency.  In  some  cases  pitting  on  pressure  may  result, 
but  not  to  the  extent  seen  in  sclercedema.  In  some  cases,  where  the 
disease  has  extended  over  a  large  surface,  the  body  may  be  taken  up 
and  will  remain  stiff  and  extended  like  a  corpse.  The  respirations 
are  very  shallow  and  reduced  in  frequency,  16  to  18  a  minute.  The 
heart  is  weak,  its  frequency  reduced  from  80  to  60  or  even  30  beats 
a  minute. 

The  temperature  is  low  (much  lower  than  in  the  scleroedematous 
form).  It  may  fall  to  30°,  26°,  or  even  22°  C.  (86°,  78.8°,  or  71.6° 
F.).  If  a  complicating  infection  is  present,  such  as  pneumonia,  the 
temperature  may  rise  to  near  the  normal.  The  urine  is  diminished 
in  quantity,  dark,  concentrated,  contains  albumin,  casts,  urates,  and 
uric  acid.  If  there  is  a  complicating  condition,  it  is  generally  one 
of  the  exhausting  diseases,  such  as  summer  diarrhoea,  cholera  infan- 
tum, or  septic  pneumonia.  Exitus  lethalis,  as  in  the  previous  form, 
takes  place  under  conditions  of  progressive  failure  of  the  respiration, 
reduction  of  temperature,  failure  of  the  heart,  unconsciousness,  and 
coma. 

Morbid  Anatomy. — The  skin  and  subcutaneous  tissues  postmortem 
retain  the  characteristics  seen  during  life.  If  cut  into,  no  fluid 
exudes,  and  very  little  bathes  the  surface  of  the  section  as  compared 
with  what  is  seen  in  scleroedema,  where  considerable  fluid  exudes 
from  the  cut  surface.  The  tissues  are  dry  (very  much  like  frozen 
fat).  Atelectasis,  pneumonia,  oedema  of  the  lung,  pleuritis,  peri- 
carditis, hemorrhages,  enlarged  spleen,  and  fatty  degeneration  of  the 
liver  and  kidneys  may  be  present  as  complicating  conditions,  with 
or  without  intestinal  catarrh.  In  the  brain,  hyperemia  and  hemor- 
rhages have  been  recorded. 

Duration. — The  duration  of  the  disease  is  from  two  to  seven  days. 

Diagnosis. — To  diagnose  either  of  these  forms  from  the  symptoms 
just  detailed  is  not  difficult;  but  I  have  seen  it  mistaken  for  the 
oedema  of  nephritis.  On  examination  such  a  mistake  can  easily  be 
rectified,  for  in  nephritis  certain  features  of  sclerema  are  absent,  such 
as  reduction  of  temperature,  lardaceous,  corpse-like  feel  of  the  skin, 
the  lack  of  resiliency,  especially  in  the  fat  sclerematous  form.  In 
infants  the  skin  may  even  retain  its  original  wrinkled  appearance, 
and  the  deeper  tissues  of  the  skin  have  the  characteristics  described. 
On  the  other  hand,  nephritis  may  complicate  scleroedema  or  fat- 
sclerema.  \ 


228  DISEASES  OF  THE  NEWBOBN. 

Sclerema  must  not  be  confounded  with  a  similar  disease  which 
occurs  in  the  adult  subject  and  older  children.  Sclerema  of  the 
newborn  and  scleroedema  do  not  appear,  as  in  the  adult,  in  patches, 
but  involve  whole  regions  and  extremities.  This  condition  of  the 
newborn  must  not  be  confounded  with  sclerodactylia,  which  is  seen 
in  adults  and  older  children. 

Prognosis. — The  prognosis  of  fat-sclerema  is  not  necessarily  fatal, 
if  primary  and  not  complicated  with  any  exhausting  condition;  if 
secondary,  as  has  been  stated,  it  is  the  forerunner  of  death. 

Treatment. — Inasmuch  as  these  infants  have  not  only  a  reduced 
temperature,  but  a  tendency  toward  a  constant  progressive  reduction 
of  the  internal  temperature,  they  should  be  put  in  some  form  of 
incubator,  and  the  same  methods  applied  as  in  the  care  of  premature 
infants.  Oxygen  is  administered  to  stimulate  not  only  the  respira- 
tions, but  the  heart.  If  the  sclerema  is  not  too  general  the  parts 
may  be  massaged  with  camphorated  oil;  and  I  have  seen  some  cases 
in  which  a  decided  improvement  followed  such  treatment.  Cardiac 
stimulants  are  used  to  arouse  the  flagging  circulation.  The  best 
drugs  to  'employ  are  caffein  and  strychnin,  with  or  without  ammo- 
nium carbonate.  To  these  infants  we  must  give  very  small  doses, 
■|  grain  of  citrate  of  caffein  every  few  hours,  or  Ysoo  grain  of  strych- 
nin, or  :j  grain  of  ammonium  carbonate.  In  many  of  these  cases 
the  act  of  nursing  is  impossible,  and  they  must  be  fed  with  the  pipette. 
If  unable  to  swallow  they  must  be  fed  by  gavage  or  per  rectum.  The 
subcutaneous  injection  of  fluids,  in  my  hands  at  least,  has  been  of  no 
avail ;  therefore  the  hyj)odermoclysis  is  of  very  little  utility. 

OPHTHALMIA    NEONATORUM. 

(Conjunctivitis  Blennorrhceica.) 

Ophthalmia  neonatorum  is  an  inflammation  of  the  conjunctiva, 
accompanied  by  a  profuse  secretion  of  pus,  and  in  some  cases  an 
inflammation  of  the  cornea.  It  is  a  specific  inflammation  of  the 
conjunctiva  due  to  the  gonococcus  of  ISTeisser.  From  30  to  40  per 
cent,  of  the  children  in  the  institutions  for  the  blind  have  lost  their 
sight  through  this  disease. 

Etiology.- — The  infant  may  be  infected  during  labor  or  after  birth. 
It  may  be  infected  immediately  after  birth,  or  some  time  subsequent 
to  delivery.  In  those  cases  in  which  the  disease  appears  from  twelve 
to  twenty-four  hours  after  birth,  they  may  be  safely  said  to  have  been 
infected  in  the  passage  through  the  parturient  canal.  In  those  cases 
infected  after  birth  the  symptoms  appear  in  from  three  to  four  days 
post  partum.  Finally,  children  may  be  infected  at  any  period  in 
the  puerperium. 


OPHTHALMIA  NEONATOBUM.  229 

The  sources  of  infection  are  the  secretions  from  the  parturient 
canal  of  the  mother,  or  infectious  material  conveyed  to  the  eyes  of 
the  infant  by  the  finger  of  the  nurse  or  accoucheur.  The  infection 
post  partum  occurs  by  direct  contact  of  the  gonococci  with  the  orbital 
conjunctiva.  In  institutions,  infections  are  ten  times  as  frequent  as 
in  private  practice,  where  the  disease,  at  least  on  the  continent  of 
Europe,  occurs  in  0.1  per  cent,  of  births  (Silex). 

Symptoms. — From  three  to  five  days  after  birth  it  is  noticed  that 
the  conjunctivse  are  red  and  swollen;  there  is  an  injection  of  the 
sclera,  swelling  of  the  lids,  and  increased  temperature  of  the  parts, 
or  possibly  oedema  and  profuse  secretion,  at  first  of  a  thin,  yellow, 
serous  discharge,  which  after  two  days  becomes  thick  and  creamy. 
The  swelling  of  the  lids  is  quite  marked;  the  eyes  are  closed.  In 
some  cases  the  palpebral  conjunctiva  protrudes  from  between  the 
orbital  fissure  and  a  profuse  creamy  pus  exudes  from  between  the 
eyelids.  If  the  child  has  icterus,  this  pus  may  assume  an  icteric 
color.  The  cornea  is  hazy,  covered  with  secretion,  and  shreds  of 
pseudomembrane  may  adhere  to  the  palpebral  conjunctiva,  especially 
in  the  early  stages  of  the  disease,  thus  simulating  diphtheritic  infec- 
tion. If  not  controlled  the  inflammation  of  the  eye  progresses  until 
the  whole  depth  of  the  cornea  is  involved,  resulting  in  perforation 
and  prolapsus  of  the  iris,  escape  of  the  humor,  and  consequent 
panophthalmitis.  The  constitutional  symptoms  in  these  cases  consist 
of  a  lack  of  desire  to  nurse  on  the  part  of  the  infant,  and  a  slightly 
elevated  temperature.  If  the  infant  is  premature  or  the  subject  of 
any  dyscrasia,  the  constant  chilling  which  takes  place  as  a  result  of 
cold  applications  to  the  eyes  results  either  in  a  loss  of  or  stationary 
weight.  Therefore  this  disease  is  more  serious  if  it  occurs  in  bottle- 
fed  than  in  breast-fed  infants. 

Duration. — The  duration  of  the  disease  varies  according  to  the 
intensity  of  the  infection.  As  a  rule,  it  lasts  three  or  four  weeks, 
when  subacute,  the  secretion  becomes  mucoid  or  serous. 

Complications.' — The  complications,  so  far  as  the  eye  is  concerned, 
are  keratitis,  with  perforation  of  the  cornea  and  loss  of  the  eye.  In 
some  cases  arthritis  of  a  gonorrhoeal  nature  has  been  observed  as  a 
complication;  in  others,  vulvovaginitis  may  result  as  a  complicating 
infection. 

Diagnosis. — The  diagnosis  presents  no  difficulties.  There  is  a 
simple  inflammation  of  the  eyes  occurring  in  newborn  infants  which 
is  not  gonorrhoeal  in  its  nature,  but  in  which  the  local  symptoms  are 
not  very  marked;  in  fact,  so  mild  as  to  raise  a  suspicion  at  once  of 
its  non-specific  nature.  In  other  cases  of  ordinary  non-specific  con- 
junctivitis, chemosis,  swelling,  and  oedema  of  the  lids  are  not  marked 
as  compared  to  what  is  seen  in  the  gonorrhoeal  form.     The  amount 


2:30  DISEASES  OF  THE  XEWBOEN. 

of  pns  secreted  is  not  great,  and  the  course  of  the  disease  is,  as  a  rule, 
benign.  We  should,  however,  before  deciding  as  to  the  innocent 
nature  of  a  conjunctivitis  in  the  newborn  make  a  spread  of  the  pus 
on  a  cover-glass  and  stain  the  same  for  gonococci,  as  this  is  the  only 
certain  method  of  determining  the  nature  of  the  disease.  In  doubtful 
cases  a  culture  will  be  demanded.  Clinically,  however,  the  two  forms 
of  conjunctivitis  are  so  distinct  that  we  may  suspect  the  one  or  the 
other  from  the  mildness  or  the  severity  of  the  local  symptoms. 

Prognosis. — The  prognosis  is  grave  in  all  cases.  A  favorable 
issue  will  always  depend  on  an  early  recognition  of  the  disease.  If 
the  disease  is  recogTiized  late  in  its  course,  the  prognosis  becomes  not 
only  doubtful,  but  grave  as  to  the  integrity  of  the  organ. 

Treatment. — The  physician  will  understand  that  above  all  things 
cleanliness  is  the  first  factor  in  the  prevention  of  this  dread  affection. 
In  private  practice,  we  may  be  able  to  judge,  from  a  knowledge  of 
the  patient  and  her  previous  condition,  as  to  the  necessity  of  certain 
measures,  which  will  be  mentioned.  If  we  are  cleanly,  however, 
some  authors  insist  that  not  only  in  private  practice,  but  in  insti- 
tutions, the  severer  methods  of  prophylaxis  will  remain  superfluous. 

We  may  state  that  the  principal  method  of  prophylaxis  in  the 
past,  and  at  the  present  day,  is  the  so-called  Crede  method  of  pro- 
phylaxis of  gonorrhoeal  ophthalmia,  and  this  consists  in  the  instilla- 
tion of  a  drop  of  a  2  per  cent,  solution  of  nitrate  of  silver  into  the 
eye  immediately  after  birth.  In  ordinary  cases  of  head  presentation 
it  is  contended  that  if  the  parts  of  the  mother  are  cleansed  just  before 
the  birth  of  the  head,  and  if  after  the  head  is  born  the  eyes  are  care- 
fully but  energetically  washed  with  sterilized  water,  better  results 
are  obtained  when  large  niunbers  of  cases  are  treated  than  by  the 
Crede  method.  Therefore,  although  in  institutions  it  may  be  advis- 
able to  apply  the  Crede  method,  on  account  of  the  number  of  cases 
which  are  there  treated,  it  is  insisted  that  in  private  practice  this 
method  remains  superfluous.  A  small  dish  of  sterilized  water  should 
be  close  by,  and  while  one  hand  supports  the  crowning  head  the  other 
should  wash  the  eyes  carefully  with  the  sterilized  water  before  the 
child  is  born,  and  the  complete  washing  of  the  eyes  can  then  be 
repeated  after  the  birth  of  the  child.  By  this,  the  Kaltenbach, 
method  of  procedure  only  0.3  per  cent,  of  eases  to  the  thousand  are 
infected:  whereas  the  combined  results  of  the  Crede  method  have  not 
been  lower  than  0.6  per  cent,  per  1000.  on  account  of  the  various 
methods  of  carrving  out  the  Crede  procedure ;  though  Crede  himself 
obtained  as  low  a  percentage  as  0.1  in  2000  cases. 

The  disease  once  inaugurated,  the  following  treatment  may  be 
formulated:  The  eyes  are  cleansed,  every  half-hour  to  an  hour,  with 
a  1 :  1000  solution  of  corrosive  sublimate.     The  eye  is  opened,  and 


MASTITIS.  231 

with  drj  cotton  the  excess  of  secretion  removed,  and  then  the  remain- 
ing secretion  washed  away  with  the  snblimate  solution.  Small  pieces 
of  lint,  cut  to  a  size  slightly  larger  than  the  eye,  are  kept  on  ice  and 
applied  every  two  to  five  minutes.  The  child  is  kept  warm;  other- 
wise with  this  treatment  the  body  may  become  chilled.  A  solution 
of  2  per  cent,  nitrate  of  silver  is  dropped  into  the  eye  daily.  Later, 
when  the  secretion  of  pus  lessens  and  the  conjunctiva  is  swollen  and 
spongy,  a  5  to  10  per  cent,  silver  solution  is  dropped  into  the  eye  and 
immediately  neutralized  with  salt  solution. 

Any  therapy  beyond  that  just  outlined  is  scarcely  within  the 
province  of  the  general  practitioner ;  but  so  important  is  immediate 
action  in  these  cases  that  every  practitioner  should  proceed  with  the 
treatment  before  calling  to  his  aid  an  ophthalmic  surgeon.  If  one 
eye  alone  is  affected,  it  is  well  to  try  to  save  the  other  eye  from 
infection,  and  there  are  several  methods  by  which  this  may  be  accom- 
plished. A  simple  method  is  to  close  the  eye,  cover  it  with  cotton, 
enough  to  fill  out  the  hollow  of  the  eye,  and  then  to  cover  this  cotton 
with  a  piece  of  lint.  Over  this  place  a  piece  of  gutta-percha  pro- 
tective, and  bind  the  eye  shut.  Such  an  eye  should  be  looked  at 
daily  before  the  affected  eye  is  treated  and  cleansed.  Should  it 
become  infected,  the  bandages  are  removed,  and  the  eye  treated  in  the 
same  manner  as  the  affected  eye. 

CAKING    OF    THE    BREASTS. 

Caking  of  the  breasts  of  the  newborn  is  not  uncommon,  and  must 
not  be  looked  upon  as  a  necessary  forerunner  of  mastitis  (Fig.  26). 

If  the  breasts  of  the  newborn  are  swollen  but  not  very  tense  they 
should  not  be  interfered  with,  as  this  is  caused  by  an  abundant  milk 
secretion,  which  soon  diminishes.  jSTo  attempt  should  be  made  to 
express  the  milk.  If  milk  e"xudes  it  should  be  carefully  washed  off 
the  breast,  and  the  breast  protected  from  traumatism  and  infection 
by  a  pad  of  sterilized  gauze.  In  exceptional  cases  the  breasts  seem 
really  tense  and  painful.  Under  those  conditions  they  may  be  gently 
massaged  once  a  day.  The  index  finger  of  the  right  hand  is  cleansed, 
anointed  with  sterilized  oil,  and  the  breast  is  stroked  in  a  circular 
direction  for  about  five  minutes.  It  is  then  cleansed  and  covered 
with  cotton  or  gauze,  as  detailed  above.  It  is  not  possible  in  the 
newborn  to  bandage  the  breasts  tightly,  as  this  procedure  interferes 
with  the  respiratory  movements  of  the  chest. 

MASTITIS. 

Mastitis  in  the  newborn  is  the  result  of  infection  of  the  breasts. 
The  organ  of  one  or  both  sides  becomes  tense  and  painful,  and  the 


232  DISEASES  OF  TEE  NEWBOBN. 

skin  covering  the  breast  becomes  red  or  bluish-purple  in  hue.  There 
are  fever  and  restlessness.  After  a  few  days  fluctuation  appears  in 
the  breast,  generally  toward  the  base  of  the  nipple. 

The  treatment  at  first  should  be  directed  toward  aborting  or 
limiting  the  inflammation.  ISTothing  is  so  effective  as  the  applica- 
tion of  small  squares  of  lint  which  have  been  moistened  with  a  weak 
solution  of  sublimate,  1 :  10,000,  and  applied  cold.  If  after  a  time 
fluctuation  appears,  incision  and  drainage  are  indicated. 

INJURIES    INFLICTED    DURING    BIRTH. 

Among  the  injuries  incident  to  birth  are  those  of  the  face.  Pres- 
sure of  the  forceps  blade  may  cause  facial  paralysis.  This,  as  a  rule, 
disappears  in  time,  though  in  severe  injury  of  the  nerves  it  may 
remain  permanent.  Indentations  of  the  cranial  bones  may  result 
from  the  pressure  of  instruments.  In  these  cases  the  bone  is  depressed, 
and  in  the  space  between  the  scalp  and  bone  there  is  an  effusion. 
The  edge  of  the  bone  surrounding  the  depression  is  distinctly  felt. 
These  depressions  need  no  treatment,  as  they  disappear  in  time. 

Paralysis. — Traction  on  the  arm  may  cause  a  so-called  birth  palsy, 
which  is  the  counterpart  of  Erb's  palsy  in  later  life.  The  i^aralysis 
in  these  cases  sometimes  remains  permanent.  Others  recover.  As 
a  rule,  one  arm  is  affected,  but  in  rare  cases  both  arms  may  be  par- 
alyzed. The  symptoms  are  characteristic.  In  a  few  days  or  at  a 
later  period  after  birth  it  is  noticed  that  the  infant  does  not  move 
one  or  the  other  arm  (Fig.  28).  The  affected  limb  hangs  loosely 
and  without  power  of  motion.  The  fingers  or  hands  may  be  mobile. 
The  affected  arm  is  cold  and  the  hand  may  be  bluish  in  tint.  After 
a  time  atrophy  of  the  muscles  about  the  shoulder- joint  may  set  in. 
The  bony  prominences  then  come  into  relief.  If  the  arm  does  not 
recover  power,  the  muscles  continue  to  atrophy,  and  there  may  be 
subluxation  of  the  head  of  the  humerus  at  the  shoulder-joint.  The 
child  in  these  cases  always  holds  the  injured  arm  with  the  sound 
one,  in  order  to  protect  and  support  it.  At  the  early  period  the  reac- 
tions of  degeneration  are  present,  and  if  the  muscles  recover,  the 
reaction  to  the  galvanic  and  faradic  current  becomes  normal.  If 
recovery  does  not  take  place,  the  disappearance  of  galvanic  and  faradic 
irritability  of  muscle  goes  hand  in  hand  with  the  muscular  atrophy. 

Treatment. — The  treatment  of  these  obstetrical  palsies  is  similar 
to  that  of  Erb's  palsy.  The  arm  is  protected  from  traumatism. 
Massage  is  performed  within  two  weeks  after  injury,  and  after  fonr 
weeks  the  faradic  current  is  applied  to  cause  muscular  contraction. 
Electricity  is  applied  for  a  short  space  of  time  daily.  The  progress 
of  these  cases  can  best  be  judged  under  treatment.     As  a  rule,  recovery 


PLATE  VIII 


Torticollis  Originating  in  a  Traumatism  at  Birth.     Hematoma 
of  the  Sternomastoid  Muscle. 


INJURIES  INFLICTED  DUBING  BIBTH. 


')  P.R 


takes  place  in  a  few  weeks.  In  other  cases  recovery  may  be  delayed. 
In  a  third  set  of  cases  recovery  never  takes  place.  The  galvanic 
and  faradic  contractility  disappears  from  the  muscle  and  nerve,  and 
permanent  atrophy  and  disability  remain.  In  these  cases  there  is 
also  retarded  growth  of  the  bone.  It  may  be  mentioned  that  in  rare 
cases  pressure  of  the  forceps  blade  has  caused  a  paralysis  of  the  hypo- 
glossal nerve  and  consequent  paralysis  of  one  or  other  half  of  the 
tongue.  Every  time  the  infant  nurses  there  will  be  in  such  cases 
great  difficulty  in  swallowing.     The  infant  will  cough  and  become 

Fig.  29. 


Birth  palsy  afEecting  the  left  arm,  atrophy  of  the  muscles  about  the  shoulder. 


cyanosed.  These  infants  must  be  nursed  slowly  or  with  a  pipette 
until  the  tongue  has  recovered  power. 

Hsematoma  of  the  Sternomastoid  Muscle. — This  affection  is  the 
direct  result  of  traumatism  during  delivery.  As  a  rule,  it  is  seen 
in  cases  of  breech  presentation  in  which  traction  has  been  exerted  on 
the  after-coming  head. 

Symptoms. — In  the  majority  of  the  cases  coming  under  my  obser- 
vation the  sternomastoid  muscle  of  the  right  side  was  affected  (Plate 
VIII. ).  The  infant  holds  the  head  on  one  side.  The  muscle  of  the 
affected  side  is  contracted,  and  the  position  of  the  head  is  that  seen 
in  torticollis.  A  hard  nodule  is  felt  along  the  inner  border  of  the 
sternomastoid  muscle,  about  the  junction  of  the  lower  third  and  upper 
two-thirds.  The  tumor  is  usually  the  size  of  a  small  hazelnut,  but 
may  be  much  larger.  Manipulation  causes  pain.  The  skin  oyer  the 
tumor  is  movable  and  not  discolored. 


234  DISEASES  OF  TEE  NEWBOBN. 

Course. — The  progress  of  the  affection  in  all  of  these  cases  is  much 
the  same.  The  tumor  becomes  smaller  as  the  exudate  is  absorbed, 
but  the  torticollis  persists,  although  in  time  this  mav  disappear.  The 
nature  of  these  tumors  is  probably  that  of  a  hematoma  caused  by 
rupture  of  muscular  fibres  and  bloodvessels. 

Treatment. — The  treatment  is  simple.  At  first  the  tumor  should 
be  let  alone.  After  a  few  days  gentle  massage  with  the  fingers 
moistened  with  oil  is  permissible.  When  the  growth  hardens  the 
massage  may  be  more  vigorous,  and  be  supplemented  with  an  attempt 
at  each  sitting  to  turn  the  head  gently  to  the  opposite  side  and  thus 
stretch  the  contracted  muscle.  Cases  which  do  not  recover  must  be 
treated  by  surgical  means  later  in  life. 

Cephalohaematoma. — Cephalohsematoma  is  an  effusion  of  blood 
between  the  pericranium  and  the  skull-cap.  The  pericranium  and 
scalp  are  raised  into  a  distinct  tumor.  In  external  cephalohsematoma 
the  effusion  is  between  the  pericranium  and  the  skull;  in  internal 
cephalohsematoma  it  is  between  the  dura  mater  and  the  skull.  Kee 
found  both  forms  present  in  the  same  patient  in  9  out  of  20  cases. 

Symptoms. — There  is  a  tumor  varying  in  size  from  that  of  a  hazel- 
nut to  that  of  an  orange,  of  elastic  consistency,  situated  in  most  cases 
on  one  or  the  other  parietal  bone.  It  is  round,  elongated,  or  kidney- 
shaped.  It  covers  part  or  the  whole  of  the  bone,  but  never  extends 
beyond  the  sutures.  The  skin  over  the  tumor  is  not  sensitive  to  the 
touch,  is  normal  or  slightly  bluish  in  color,  and  is  perfectly  movable 
over  the  tumor.  After  a  few  days  the  circumference  of  the  tumor  is 
bounded  by  a  distinct  wall,  at  first  soft,  but  later  of  bony  hardness. 
The  general  health  of  the  infant  remains  good  unless  there  is  a  com- 
plication. This  blood  tumor  appears  two  or  three  days  after  birth. 
At  first  it  is  tense,  but  afterward  becomes  softer  and  doughy  to  the 
touch.  It  reaches  its  maximum  size  in  from  six  to  eight  days.  It 
begins  to  diminish  in  the  second  week,  and  disappears  by  the  fifteenth 
week.  The  tumor  is  either  absorbed  or  there  is  a  proliferation  of 
bone,  which  remains  as  an  exostosis.  At  this  time  crepitation  resem- 
bling that  of  parchment  is  felt.  Around  the  former  tumor  a  thin 
wall  of  bone  is  found. 

Occurrence. — These  tumors  are  not  common.  Hennig  found  230 
cases  in  53,50G  births,  or  0.43  per  cent,  of  the  whole  number.  Hof- 
mokl's  statistics  give  a  like  figure.  Most  of  the  cases  are  vertex 
presentations.  The  cephalohsematoma  usually  occurs  on  the  right 
parietal  bone,  and  may  follow  easy  as  well  as  difficult  labors.  It  is 
present  oftener  in  boys  than  in  girls,  and  is  seen  in  premature  infants 
as  well  as  full-term  babies.  It  has  been  observed  in  breech  cases, 
especially  if  forceps  has  been  applied  to  the  after-coming  head. 
These  tumors  may  occur  on  both  parietal  bones  of  the  infant.  In 
such  cases  the  sagittal  suture  distinctly  separates  the  two  tumors. 


INJURIES  INFLICTED  DURING  BIRTH.  235 

Complications. — Internal  cephalohsematoma,  or  cerebral  hemor- 
rhage, may  complicate  the  external  tumor.  In  such  cases  there  has 
been  a  difficult  labor  with  the  application  of  forceps.  The  majority 
of  the  infants  thus  affected  die.  Suppuration  of  the  tumor  may  take 
place,  or  diffuse  cranial  phlegmon  may  result  fatally.  A  section  of 
a  cephalohsematoma  shows  the  scalp  to  be  studded  with  punctate  hem- 
orrhages. The  pericranium  is  bluish  and  covered  with  hemorrhages, 
and  is  separated  from  the  skull  by  a  collection  of  fluid  blood  under 
great  tension.  The  bone  beneath  is  rough  or  covered  with  a  few 
clots.  A  bony  wall  is  seen  around  the  circumference  of  the  tumor. 
It  is  a  periosteal  formation.  After  a  time  the  bone  and  the  inner 
surface  of  the  pericranium  become  coated  with  a  gelatinous  exudate, 
which  is  subsequently  converted  into  bone.  In  some  cases  quite  an 
extensive  bloody  effusion  is  found  between  the  dura  and  skull. 

The  situation  of  the  cephalohsematoma  always  corresponds  to  the 
position  of  certain  natural  fissures  which  exist  in  the  posterior  part 
of  both  parietal  bones,  running  from  the  sagittal  suture.  In  the 
occipital  bone  these  fissures  radiate  from  the  lateral  fontanelles  and 
separate  the  upper  and  the  inferior  part  of  the  occipital  bone. 

Pathogenesis. — A  cephalohsematoma  is  the  result  of  the  bursting 
of  a  small  vessel  between  the  periosteum  and  bone,  and  at  the  situation 
of  the  caput  succedaneum.  Hence  the  frequent  formation  of  the 
tumor  on  the  right  parietal  bone.  It  is  most  common  in  first-born 
infants.  Asphyxia  of  the  infant  favors  the  formation  of  the  tumor. 
Cephalohsematoma  may  also  occur  as  a  part  of  the  hemorrhagic 
symptomatology  in  general  diseases,  such  as  syphilis,  sepsis,  and 
Buhl's  disease. 

Diagnosis. — The  diagnosis  is  made  from  the  presence  of  an  elastic 
fluctuating  tumor  distinctly  limited  by  suture  and  surrounded  by  a 
ring  or  wall.  A  caput  succedaneum  is  (Edematous  and  bluish,  is  seen 
immediately  after  birth,  passes  beyond  the  sutures,  does  not  fluctuate, 
and  disappears  shortly  after  birth.  A  hernia  of  the  brain  does  not 
fluctuate,  grows  tense  when  the  infant  cries,  and  shows  respiratory 
fluctuations  and  pulsation.  It  can  be  reduced.  Abscess  of  the  scalp 
is  painful,  hot,  and  red;  the  phlegmon  spreads  over  the  whole  scalp 
and  is  accompanied  by  oedema  of  the  whole  region.  If  cerebral 
symptoms  are  present  with  a  cephalohsematoma,  they  point  to  corre- 
sponding internal  effusion  or  cerebral  hemorrhage. 

Prognosis. — The  prognosis  is  good  if  there  is  no  internal  tumor 
or  cerebral  hemorrhage,  or  if  infection  of  the  external  tumor  with 
resulting  abscess  does  not  occur.  Even  the  latter,  however,  does  not 
preclude  the  possibility  of  recovery.  The  prognosis  is  bad  if  the 
cephalohsematoma  is  part  of  a  general  hemorrhagic  condition,  as  in' 
syphilis,  fatty  degeneration,  or  sepsis. 


236  DISEASES  OF  THE  NEWBOBN. 

Treatment. — Uncomplicated  cephalohamatomata  are  absorbed  if 
let  alone.  If  abscess  occurs,  the  tiunor  should  be  opened  under  anti- 
septic precautions,  evacuated,  and  the  sac  packed  with  iodoform  gauze. 

On  the  other  hand,  even  in  the  early  stage,  the  tumor  may  be 
large  and  tense,  and  cerebral  symptoms  may  be  present.  Such  effu- 
sions of  blood  may  communicate  with  an  internal  tumor  through 
the  parietal  or  occipital  fissures  mentioned.  In  such  very  excep- 
tional cases  aspiration  to  relieve  internal  pressure  may  be  justifiable 
(Runge) . 

Note. — For  other  injuries  attending  birtli  see  article  Cerebral  Palsy  or  Little's 
Disease. 


SECTION  IV. 

DISEASES  DUE  TO  DISTURBANCES  OF  NUTRITION. 

RACHITIS. 

(Riclcets.) 

Rachitis  is  a  disease  of  nutritioii  causing  well-marked  changes 
in  the  structure  and  form  of  the  growing  bones.  It  is  peculiar  to 
infancy  and  childhood  and  does  not  occur  after  the  skeleton  is  formed. 

Etiology. — There  are  two  forms  of  rachitis,  the  congenital  or  foetal 
and  the  post-natal. 

The  occurrence  of  congenital,  foetal,  or  intra-uterine  rachitis  is 
still  a  subject  of  much  difference  of  opinion.  According  to  some 
authorities  (Kassowitz),  80  per  cent,  of  the  infants  of  the  Vienna 
Maternity  Hospital  show  evidences  of  rachitis.  Epstein  at  one  time 
demonstrated  to  me  the  great  frequency  of  rachitic  deformity  at  the 
costochondral  junction  of  the  ribs,  in  the  infants  of  the  Maternity 
Hospital  in  Prague. 

Congenital  Rachitis. — There  can  be  no  doubt  of  the  existence  of 
such  a  condition  as  rachitis  in  utero,  or  congenital  rachitis.  In  these 
cases  the  infant  at  birth  has  craniotabes,  or,  if  closely  examined,  the 
rosary  and  other  marks  of  the  true  rachitic  process  on  the  long  bones 
may  easily  be  made  out.  We  must  not  confound  such  cases  with 
what  has  been  called  foetal  rickets.  The  latter  term,  as  will  be  seen, 
has  been  practically  abandoned,  and  was  at  one  time  applied  to  cases 
of  chondrodystrophia.  It  is  not  at  all  a  rachitic  process,  and  has 
nothing  in  common  with  rachitis.  Virchow  insists  that  foetal  rachitis 
in  the  true  sense  is  rare,  and  that  an  anomaly  in  the  development  of 
the  primordial  cartilage  has  been  mistaken  for  rachitis,  with  which  it 
has  nothing  in  common. 

Hemorrhagic  rachitis  is  a  term  applied  by  some  authors  to  Bar- 
low's disease  or  infantile  scurvy.  Rachitis  is  for  the  most  part  post- 
natal, and  its  onset  occurs  most  frequently  during  the  first  year  of 
life.  It  is  rare  after  the  third  year.  The  sexes  are  equally  subject 
to  the  disease.  A  moist  climate  favors  it.  It  is  very  common  in 
Germany  and  Austria,  and  is  rarely  met  in  southern  Asia  or  Central 
America.  Fischl  insists  that  it  is  peculiar  to  some  races  of  people, 
and  Snow,  of  Buffalo,  has  shown  that  Italians  living  in  America 
are  peculiarly  subject  to  it.  It  is  most  common  among  civilized  com- 
munities, in  which  infants,  especially  those  of  large  cities,  are  fed 

237 


238  DISEASES  DUE  TO  DISTURBANCES  OF  NUTRITION. 

upon  substitutes  for  breast  milk.  On  the  other  band,  breast-fed 
infants  may  develop  rachitis,  but  in  such  cases  investigation  of  the 
milk  by  Pfeiffer  and  others  has  not  resulted  in  the  discovery  of  any 
peculiarity  of  the  milk  which  might  be  looked  upon  as  a  causative  . 
factor.  Rachitis  develops  in  infants  who  have  been  weaned  from  the 
breast  early  and  fed  on  artificial  foods  or  sterilized  milk.  The  early 
introduction  of  meats  and  solid  food  into  the  dietary  of  the  infant  has 
been  cited  as  an  etiological  factor. 

That  syphilis  is  a  direct  causative  agent  in  rachitis  (Parrot)  can 
no  longer  be  accepted.  Heredity  does  not  seem  to  exert  any  influ- 
ence. There  are  many  theories  as  to  the  active  and  immediate 
causes.  The  principal  theories  are  those  which  presuppose  the  lack 
of  some  element,  such  as  phosphates  or  lime  salts,  in  the  food,  and 
those  that  trace  the  processes  of  rachitis  to  a  disturbance  of  nutritive 
functions  caused  by  an  increase  of  certain  acids  (lactic)  in  the 
stomach,  a  diminution  of  others  (hydrochloric)  and  resulting  intes- 
tinal functional  irregularities  (Monti,  Zander).  The  intestinal  dis- 
turbances cause  the  elimination  of  certain  salts  from  food,  hence  the 
blood  fails  to  receive  what  is  necessary  for  the  structure  and  forma- 
tion of  the  bones. 

Morbid  Anatomy. — Rachitis  is  anatomically  characterized  by  proc- 
esses which  cause  an  increased  resorption  of  bone,  deficient  calci- 
fication of  cartilage,  and  the  formation  of  a  characteristic  tissue — a 
deficiently  calcified  bone,  the  so-called  osteoid  tissue  (Ziegler,  Kasso- 
witz,  Schmorl).  The  increased  resorption  consists  in  an  augmenta- 
tion of  the  number  of  areas  of  lacunar  absorption.  In  marked 
rachitis  the  greater  part  of  the  bony  skeleton  is  lost.  The  cortical 
area  of  the  long  and  of  the  short  bones  becomes  osteoporous.  A 
large  part  of  the  lamellae  of  the  cancellous  bone  is  absorbed  and  dis- 
appears. In  the  flat  bones  the  arrangement  of  outer  and  inner  table 
separated  by  the  intervening  diploe  is  lost.  The  bone  tissue  is  re- 
duced to  a  few  lamellae.  At  the  zones  of  periosteal  and  medullary 
ossification,  the  lamellae  are  replaced  by  osteoid  tissue.  This  tissue 
is  a  new  formation  devoid  of  lime  salts. 

The  marrow  of  the  osteoid  tissue  formed  from  the  periosteum  or 
medullary  canal  consists  of  a  reticulum  of  striated  connective  tissue 
rich  in  bloodvessels  and  enclosing  free  round  cells.  Beneath  the 
periosteum  of  the  cranial  and  long  bones  there  is  formed,  because  of 
these  changes,  a  spongy  vascular  tissue  which  is  resistant  to  pressure 
and  may  be  cut  with  a  knife.  While  the  rachitic  process  lasts,  no 
lime  salts  appear  in  the  lamellae  of  osteoid  tissue,  but  as  soon  as  the 
disease  has  spent  itself  those  salts  appear  in  the  centre  of  the  lamellae. 
Complete  recovery  results  in  calcification  of  these  lamellae,  which 
being  proliferated  leave  the  bone  hardened  and  very  much  thickened. 


EACHITIS.  239 

The  pathological  change  in  the  endochondral  ossification  consists  in 
an  entire  absence  of  a  calcification  zone.  In  severe  rachitis,  all  signs 
of  the  deposit  of  lime  salts  are  absent.  There  is  a  widening  of  the 
zone  of  proliferation  of  cartilage  cells,  and  also  of  the  columns  of 
hypertrophied  cartilage  cells.  There  is  lastly  an  irregular  formation 
of  vascular  marrow-spaces,  which  grow  here  and  there  into  the  car- 
tilage from  the  bone.  Thus  at  the  junction  of  cartilage  and  bone, 
there  is  in  the  long  bones  no  distinct  line  of  ossification.  The  red 
marrow-spaces  extend  for  varying  distances  into  the  cartilage. 

The  abundant  growth  of  bloodvessels  extending  from  the  peri- 
chondrium into  the  cartilage  is  accompanied  by  the  substitution  of 
osteoid  tissue  and  marrow-spaces  for  the  cartilage  proper,  as  in 
periosteal  and  medullary  ossifications.  In  rachitis  the  cartilage  is 
never  completely  absorbed  by  osteoid  tissue.  Thus,  on  section,  the 
bone  shows,  nearest  the  cartilage,  the  zone  of  proliferating  cartilage- 
cells  with  hypertrophied  cells  in  columns ;  next  to  this  is  the  zone 
of  osteoid  tissue  in  lamellae  in  which  few  lime  salts  are  deposited. 
ISTearer  the  bone  are  lamellae  of  osteoid  tissue,  in  the  centre  of  which 
fully  formed  bone  is  deposited. 

The  lamellae  of  osteoid  tissue  differ  from  those  of  normal  bone  in 
being  much  thicker  and  more  abundant.  The  osteoid  tissue  is  very 
resilient  and  easily  bent,  hence  this  property  of  rachitic  bones.  The 
process  leaves  the  bones  much  thickened,  especially  at  the  epiphyseal 
extremities.  The  deformities  of  the  chest,  extremities,  pelvis,  and 
spine  can  thus  be  traced  to  the  tendency  of  the  rachitic  bone  to  bend 
on  pressure  and  traction.  The  effects  of  the  process  on  the  shape  of 
the  cranium  and  the  delay  in  the  formation  of  the  teeth  may  thus  be 
easily  accounted  for. 

Among  other  gross  lesions  connected  with  the  clinical  picture  of 
rachitis  is  enlargement  of  the  spleen.  The  organ  may  be  very  large 
and  easily  palpated  below  the  border  of  the  ribs.  Sasuchin  found 
that  of  66  cases  of  rachitis,  the  spleen  was  enlarged  in  12  to  15  per 
cent.  The  changes  in  the  organ  consisted  in  thickening  of  the  cap- 
sule and  proliferation  of  the  connective  tissue  of  the  organ,  thickening 
of  the  walls  of  the  arteries,  atrophy  and  obliteration  of  the  Malpighian 
bodies,  and  anaemia  of  the  organ.  This  important  blood-distributing 
organ  is  thus  compromised.  The  spleen  may  be  increased  to  two  and 
a  half  times  its  normal  size. 

The  liver  may  also  be  apparently  enlarged.  During  life  the 
enlargement  of  the  liver  may  be  more  apparent  than  real.  The  chest,- 
if  narrow  and  deformed,  may  cause  downward  displacement  and  rota- 
tion of  that  organ.  In  rachitic  infants  the  lymph-nodes  are  more 
apparent  on  palpation  than  is  normal.  They,  however,  are  never 
increased  to  the  size  attained  in  tuberculosis,  syphilis,  or  eruptions 


240  DISEASES  DUE  TO  DISTURBANCES  OF  NUTRITION. 

of  the  skin,  such,  as  those  of  the  exanthemata.  The  blood  may  show 
the  changes  of  extreme  simple  anaemia — an  increase  in  the  nucleated 
red  blood-cells  and  other  signs. 

Brain. — Slight  or  marked  hydrocephalus  is  frequently  found  in 
rachitis.  The  relation  between  the  two  conditions  is  not  dear.  If 
the  infant  dies  of  an  intercurrent  disease,  changes  of  a  chronic 
catarrhal  character  may  be  found  in  the  gut  and  signs  of  bronchitis 
or  persistent  bronchopneumonia  in  the  lungs.  These  conditions  follow 
the  changes  in  nutrition  which  cause  the  rachitic  processes  elsewhere. 

Sjmiptoms. — The  most  marked  and  general  symptoms  of  rachitis 
are  changes  in  the  bony  skeleton. 

The  Head. — The  shape  of  the  rachitic  head  is  characteristic. 
The  frontal  bone  bulges,  giving  the  infant  a  prominent  forehead. 
The  parietal  bones  have  a  flare,  caused  by  the  formation  of  bosses 
at  the  centres  of  ossification.  The  whole  head  has  a  cuboidal 
shape,  which,  with  the  proportionately  small  face,  gives  a  character- 
istic appearance.  The  disturbances  in  bone  formation  cause  the 
appearance  of  soft  spots,  especially  in  the  vicinity  of  the  lambdoidal 
suture.  These  (craniotabes)  may  be  membranous  in  structure.  They 
rarely  appear  on  the  frontal  bones  in  the  vicinity  of  the  coronary 
suture.  The  spots  of  craniotabes  appear  in  infants  who  develop 
rachitis  before  the  sixth  month  (Monti),  rarely  after  this  period. 
They  take  four  or  five  weeks  to  develop  fully.  In  developed  rachitis 
the  occiput  is  flat  and  devoid  of  hair  (Plate  IX.).  The  anterior 
fontanelle,^  which  normally  closes  between  the  fifteenth  and  the 
eighteenth  month,  remains  open  for  a  long  time,  in  some  cases  until 
the  third  or  fourth  year,  or  even  to  the  sixth.  The  sutures  are  also 
slow  in  closing.  The  coronary  sutures  may  remain  open  for  two,  and 
the  longitudinal  suture  for  three  years.  The  lambdoidal  suture  does 
not  in  some  cases  close  until  the  eighteenth  month. 

If  the  thorax  is  affected  by  rachitis,  the  circumference  of  the  head 
will  exceed  that  of  the  chest.  The  lower  jaw  has  an  angular  deform- 
ity, described  by  Fleischmann.  This  consists  in  a  bending  of  the 
body  of  the  jaw  at  the  situation  of  the  canine  teeth.  The  body  of 
the  jaw  is  also  rotated  internally  on  its  horizontal  axis.  If  rachitis 
begins  before  the  sixth  month,  dentition  is  delayed  for  periods  vary- 
ing up  to  a  year  and  a  half.  I  have  a  record  of  a  case  in  which  the 
first  tooth  appeared  at  the  twenty-fourth  month.  If  rachitis  develops 
after  appearance  of  the  first  teeth,  the  succeeding  ones  appear  later 
than  is  normal.     The  structure  of  the  teeth  suffers.     They  show 

'  While  the  lateral  and  posterior  fontanelles  close  during  the  first  months  of 
infancy,  the  anterior  f ontanelle  increases  in  its  longitudinal  and  transverse  diameter 
with  the  growth  of  the  cranium  up  to  the  twelfth  month.  The  growth  of  the 
anterior  fontanellc  was  first  observed  by  Elsilsser.  Although  denied  by  Kassowitz 
it  has  been  recently  proved  by  Ehode  that  the  contention  of  Elsasser  is  correct. 


PLATE   IX 


Rachitis.  Sho^A^ing  the  cuboldal  shape  of  the  head,  the 
thoracic  deformity,  the  beaded  ribs,  the  protuberant  abdo- 
men, and  the  enlarged  lower  end  of  the  radius. 


BACHITIS. 


241 


erosions,  are  easily  broken,  and  become  carious  quickly.  This  is  due 
to  imperfect  formation  of  enamel  or  dentine.  Sometimes  after  their 
eruption,  the  incisors  show  a  well-marked  incurvation  at  the  free 
border,  which  is  due  to  erosion  or  breaking  of  the  tooth. 

Thorax.— The  thorax  shows  characteristic  deformities.  Rachitis 
of  the  thorax  in  most  cases  develops  in  the  second  half  year,  and 
may  continue  into  the  third  year.     The  first  marked  sign  is  the 

Fig.  30. 


Rachitic  deformity  of  the  spine.     Uniform  curvature  backward. 


appearance  of  the  so-called  rib  rosary.  This  is  a  thickening  of  the 
costochondral  junction  of  the  rib,  in  which  the  rachitic  processes 
above  described  are  very  active.  Deformity  of  the  thorax  follows  in 
course  of  time.  The  thorax  becomes  prominent  at  the  sternum  and 
flattened  in  the  midaxillary  region  from  the  axilla  to  the  free  border 
of  the  ribs.  (Plate  IX.).  There  is  a  distinct  incurvation  of  the 
thorax  above,  and  a  .flaring  below.  The  thorax  is  much  narrowed  at 
the  clavicles,  with  a  flaring  outward  of  the  lower  ribs.  Respiration, 
especially  inspiration,  is  much  interfered  with.  The  sides  of  the 
16 


242 


DISEASES  DUE  TO  DISTUBBAXCES  OF  NUTEITION 


thorax  are  dra^^'ll  iuward  at  the  diaphragm  at  each  inspiration.  In 
an  attack  of  severe  bronchitis  or  bronchopneumonia,  the  drawing- 
inward  of  the  sides  of  the  chest  becomes  still  more  marked.  In  some 
cases  the  sternum  alone  is  aifected.  There  is  a  sinking  of  the  ster- 
num, with  resulting  chest  deformity.      Some  forms  of  rachitis  affect 

Fm.  31. 


/ 


Angulai-  deformity  of  the  spine,  due  to  Pott's  disease,  as  distinguished  from  the 
deformity  due  to  rachitis. 


only  the  ribs  or  part  of  the  thorax.  While  the  rachitic  process  is  in 
progress,  the  chest  circumference  does  not  increase;  it  begins  to  do 
so  when  the  disease  has  run  its  course  in  the  thorax. 

Fain. — When  the  infant  is  raised  from  the  chair  or  crib,  it  cries. 
This  is  the  result  of  the  painful  nature  of  the  rachitic  process  in  the 


RACHITIS.  243 

bones.  Forcible  percussion  of  the  chest  will  cause  pain.  On  account 
of  the  deformity  of  the  chest  and  the  consequent  interference  with  its 
physiological  functions,  the  lung  is  prone  to  contract  infections,  such 
as  bronchitis  and  bronchopneumonia.  Atelectasis  is  also  a  common 
complication.  The  clavicle  becomes  bent  and  fractures  on  the  slight- 
est traumatism.  At  the  termination  of  the  rachitic  process,  the 
clavicle  and  scapulae  are  much  thickened.  Virchow  has  shown  that 
the  scapula  becomes  the  seat  of  an  angular  deformity. 

Spine. — On  account  of  the  relaxation  of  the  ligaments  of  the 
bodies  of  the  vertebrae  and  of  the  rachitic  processes  in  the  bodies  of 
the  bones  themselves,  there  is  in  most  rachitic  infants  a  bending  back- 
ward of  the  dorsolumbar  spine  (Fig.  30),  The  curvature  is  very 
marked  when  the  infants  are  held  in  the  arms.  It  differs  from 
deformity  due  to  Pott's  disease  in  that  it  is  not  angular  and  in  that  = 
the  spine  can  be  straightened  and  even  curved  forward  with  ease; 
(Fig.  31). 

Lateral  curvatures  of  the  spine  are  also  found.  If  the  spinal 
deformities  occur  early  in  infancy,  they  disappear  as  the  rachitis 
heals  and  the  ligaments  and  muscles  regain  a  normal  tonicity.  On 
the  other  hand,  should  the  rachitic  process  attack  the  spine  late  in  the 
third  or  fourth  year,  the  deformities  are  perpetuated.  This  is  espe- 
cially the  case  if  the  pelvis  is  also  affected  at  that  time  (Monti). 

Pelvis. — The  pelvic  deformities  which  result  from  rachitis  are 
chiefly  flattening  of  the  pelvis,  and  the  pseudo-osteomalacic  pelvis. 

Upper  Extremities.- — The  epiphyses  are  much  swollen  and,  in 
rare  cases,  painful.  The  wrist  is  flat  and  much  broadened.  If  the 
rachitis  is  elsewhere  not  marked,  the  physician  should  be  careful  not 
to  mistake  a  normal  enlargement  in  this  situation  for  rachitis.  In 
exceptional  cases,  the  elbow  and  shoulder-joint  show  similar  changes. 

On  account  of  the  traction  of  the  flexors  and  pronators,  the  fore- 
arm may  be  incurvated  and  the  bones  twisted  on  their  longitudinal 
axes.  The  result  is  a  more  or  less  fixed  position  of  pronation  in  the 
forearm.  The  arm  is  rarely  curved  in  this  manner,  but  it  may,  like 
the  clavicle,  be  fractured  after  slight  traumatism.  As  a  result  of 
rachitis  and  deformity,  the  growth  of  the  bone  in  length  is  much 
interfered  with. 

The  phalanges  are  sometimes  the  seat  of  the  rachitic  processes. 
In  some  severe  cases  I  found  all  the  phalanges  thickened  in  the  dia- 
physes.  These  cases  bear  a  very  close  resemblance  to  dactylitis 
syphilitica,  especially  as  there  is  pain  on  pressure  (Fig.  32). 

Lower  Extremities. — The  deformities  of  the  lower  extremities 
are  more  marked  than  those  of  the  upper  ones.  On  account  of  the 
pain  experienced,  the  infants  refuse  to  stand;  they  will  draw  the 
extremities  up  underneath  the  abdomen,  if  any  effort  is  made  to 


244 


DISEASES  DUE  TO  DISTURBANCES  OF  KUTEITION. 


make  them  do  so.  In  other  cases,  when  attem]3ts  are  made  to  stand, 
the  weight  of  the  body  and  the  muscular  traction  (Kassowitz)  cause 
deformity.  The  femur,  tibise,  and  fibulae  curve  outward,  giving  the 
so-called  '"bow-leg"  deformity  (Plate  X.).  This  may  in  extreme 
cases  result  in  a  deformity  of  the  heads  of  the  bones  entering  into  the 
formation  of  the  knee-joint.  The  ankle-joint  may  suffer  a  varus 
deformity.  The  femur  and  tibiae  may  curve  inward,  and  a  knock- 
knee  deformity  result.  In  all  cases,  there  is  relaxation  of  the  liga- 
mentous joint-structure.     The  tibia  sometimes  becomes  miich  thick- 


Fw.  SS 


W^'  '^     ^^l^B  »  *  » 


Rachitic  hands,  showing  bowing  and  thickening  phalanges  of  fingers   (author's  case). 


ened  and  curves  anteriorly,  giving  the  so-called  "  sabre ''  deformity. 
It  may  be  twisted  on  its  longitudinal  axis.  I  have  seen  severe 
rachitis  of  the  femur  and  tibia  result  in  multiple  fractures. 

The  deformity  at  the  hip-joint,  which  later  in  life  follows  changes 
in  the  angle  made  by  the  neck  of  the  bone  with  the  shaft  of  the 
femur  (coxa  vara),  is  believed  to  be  due  (Whitman)  to  rachitis. 
The  children  are  late  in  walking.  The  musculature  is  weakened 
through  disuse. 

When  the  children  assume  the  sitting  posture,  they  cross  the  lower 
extremities  in  tailor  fashion.  In  the  majority  of  cases  of  rachitis, 
the  abdomen  is  protuberant.  As  a  result  of  the  defective  nutrition, 
the  musculature  of  the  intestine  is  weakened  in  the  same  manner  as 
that  of  the  extremities.     Tympanitic  distention  is  the  rule. 

Intestinal  Disturbances. — Intestinal  disturbances  are  common  in 


PLATE  X 


Rachitis.      Showing  the  deformity  of  the  thorax  and 
marked  bowing  of  the  tibiae. 


RACHITIS.  245 

rachitis,  but  are  not  a  result  of  the  process.  Henoch  shows  that 
rachitis  may  be  present  with  an  apparently  normally  functionating 
intestine. 

Spleen. — The  spleen  is  enlarged  in  many  cases  of  rachitis,  but 
retrogrades  to  the  normal  size  after  the  disease  has  run  its  course. 

Blood. — The  blood  shows  the  changes  found  in  ordinary  mild  or 
severe  simple  ansemia. 

Liver. — The  liver  may  be  slightly  enlarged. 

Anwrnia-. — Ansemia  of  the  skin  and  mucous  membranes  is  fre- 
quently found.  It  may  be  so  extreme  as  to  cause  the  skin  to  have  a 
yellowish  waxy  hue.  Rachitic  children  perspire  freely  at  night,  espe- 
cially about  the  head.  Unless  the  skin  is  kept  scrupulously  clean, 
sudamina,  furuncles,  and  eczema  of  all  kinds  will  result. 

Nervous  System.- — There  is  no  doubt  that  certain  nervous  aifec- 
tions,  such  as  tetany,  laryngismus  stridulus,  attacks  of  inspiratory 
apnoea,  spasmus  nutans  occur  frequently  in  combination  with  rachitis. 
Some  authors  (Kassowitz,  Jacobi,  Escherich)  trace  a  distinct  etiolog- 
ical connection  between  these  conditions  of  instability  of  the  nervous 
system  and  rachitis. 

Hydrocephalus. — Hydrocephalus  occurs  in  rachitic  subjects.  In 
cases  of  severe  rachitis,  an  appearance  of  mild  hydrocephalus  is  given 
to  the  face  by  a  downward  depression  of  the  eyeball.  The  sclera  of 
the  eyes  is  thus  slightly  exposed.  The  appearance  seems  to  be  caused 
by  a  depression  of  the  orbital  plates  of  the  frontal  bone  by  the  over- 
lying frontal  lobes  of  the  cerebrum.  In  many  cases  of  severe  rachitis, 
the  wide  fontanelle,  its  tenseness,  and  the  open  coronal  and  temporal 
sutures  give  a  picture  like  that  of  a  non-progressive,  mild  hydroceph- 
alus which  is  simply  a  feature  of  the  nutritive  disturbances  taking 
place  in  the  brain  as  elsewhere. 

Severity  of  the  Affection. — The  symptoms  above  detailed  are  not 
all  present  in  cases  of  rachitis.  In  some  cases  there  are  only  very 
slight  signs  of  the  disease,  such  as  a  slightly  cuboidal  shape  of  the 
head  or  a  scarcely  appreciable  bending  of  the  ribs  without  any 
deformity.  In  such  cases  even  an  expert  may  be  in  doubt  as  to  the 
presence  of  swelling  of  the  epiphyses.  In  other  cases  an  intercurrent 
affection,  such  as  tetany,  will  cause  the  physician  to  seek  for  signs 
of  rachitis,  which  may  be  so  slight  as  to  have  previously  escaped 
notice.  Craniotabes  is  sometimes  absent  in  marked  cases  of  rachitis. 
Delayed  dentition  is  not  the  rule.  Rachitis  may  be  very  evident  in 
cases  in  which  the  teeth  appear  in  their  normal  order. 

Duration. — In  such  a  disease  as  rachitis  it  is  to  be  expected  that 
the  duration  of  the  affection  will  vary  greatly.  It  may  last  months 
in  some  cases,  in  others  years.  The  first  favorable  sign  is  the  attempt 
of  the  infant  or  child  to  walk,  but  children  with  marked  and  progres- 
sive rachitis  sometimes  walk  early. 


246  DISEASES  DUE  10  DISIUEBAXCES  OF  KriEIIION. 

Increase  in  -weight  and  in  the  chest  circumference,  an  improve- 
ment in  symptoms,  such  as  ansemia  and  intestinal  disturbances,  and 
the  cessation  of  pulmonarr  complications  are  indications  that  the 
disease  has  come  to  a  standstill. 

Diagnosis. — The  diagnosis  of  rachitis  before  the  development  of 
the  physical  signs  in  the  bones  of  the  head,  chest,  and  extremities  is 
scarcely  possible.  Monti  thinks  that  an  increase  of  lactic  acid  in  the 
stomach  contents  is,  if  there  are  intestinal  disturbances,  strong  pre- 
sumptive evidence  of  early  rachitis,  but  the  increase  of  lactic  acid  may 
be  temporary,  and  the  general  practitioner  will  find  it  hard  to  esti- 
mate. Once  the  bone  symptoms  develop,  there  is  no  difficulty.  In 
cretinism.  Mongolian  idiocy,  and  syphilis,  there  are  changes  in  the 
bones  which  very  closely  resemble  those  seen  in  simple  rachitis.  Yet 
in  all  these  conditions  there  are  other  signs  which  will  make  the 
diagnosis  clear.  In  syjDhilis,  rachitis  is  frequently  an  accompanying 
condition.  There  is  no  etiological  connection  between  the  two  affec- 
tions. In  every  case  of  tetany,  spasmus  nutans,  laryngismus,  inspira- 
tory apnoea,  or  eclampsia,  the  physician  should  not  fail  to  look  for 
evidences  of  rachitis.  The  improvement  in  these  conditions  will 
often  depend  on  the  management  of  the  rachitis. 

If  the  infant  cannot  stand,  the  limbs  may  exhibit  a  variety  of 
pseudoparalysis.  Paralysis  may  be  excluded  by  making  an  electrical 
muscle  test.  Although  infants  with  rachitis  will  not  stand,  they 
move  the  lower  extremities  vigorously  when  lying  down.  This  is  not 
the  case  in  the  palsies;  the  faradic  and  galvanic  muscle  tests  and  the 
presence  of  the  normal  reflexes  will  fix  the  diagnosis.  In  severe  cases 
of  cranial  rachitis,  it  is  not  always  an  easy  task  to  exclude  hydro- 
cephalus. TVhiile  marked  hydrocephalus  presents  no  difficulties  of 
diagnosis,  a  slight  hydrocephalus  is  not  always  apparent.  In  such 
cases  the  head  circumference  is  measured  once  a  month.  An  abnor- 
mal increase  in  the  circimiference.  a  wide  tense  fontanelle.  and  open 
sutures  indicate  hydrocephalus. 

The  Blood. — Through  a  study  of  the  blood  in  rachitis  Morse  has 
come  to  the  conclusion  that  anaemia  of  any  form  may  exist.  It  is 
generally  an  ansemia  in  which  the  number  of  red  blood-cells  is  normal 
or  nearly  so.  The  haemoglobin  is  reduced,  and  there  is  a  consequent 
reduction  in  specific  gi'avity.  There  is  leucocytosis,  especially  in  the 
cases  with  splenic  enlargement. 

Rachitis  Tarda. — Eachitis  tarda  is  a  term  applied  by  Kassowitz 
and  Genser  to  those  cases  Avhich,  instead  of  running  their  course  in 
two  or  at  most  three  years,  continue  in  the  active  stage  for  eight,  ten, 
or  even  twelve  years.  Kassowitz  and  his  pujDils  record  eases  of  florid 
rachitis  at  the  tenth  and  twelfth  year.  I  have  seen  a  case  of  florid 
rachitis  in  a  female  child  eight  years  of  age.     She  had  all  the  signs 


BACHITIS.  247 

of  rachitis  of  the  head,  thorax,  and  arms.  The  lower  extremities 
were  permanently  crossed  in  tailor  fashion.  The  bones  were  painful, 
and  those  of  the  lower  extremities  were  the  seat  of  multiple  fractures. 
The  teeth  were  decayed.  In  Genser's  case  the  milk  teeth  having 
decayed  and  fallen  out,  the  permanent  ones  failed  to  appear. 

Occurrence. — West  has  demonstrated  that  rachitis  in  the  United 
States  is  not  confined  to  negroes  and  immigrants.  He  has  shown 
that  its  greatest  frequency  is  among  the  natives  of  Eastern  Ohio. 

Prognosis — If  rachitis  is  not  complicated  by  any  intercurrent 
affection,  the  prognosis  as  to  life,  even  in  the  severe  forms,  is  gener- 
ally good.  On  the  other  hand,  an  intercurrent  affection,  such  as  per- 
tussis or  bronchopneumonia,  is  likely  to  run  a  severe  course  and  prove 
fatal  in  a  rachitic  subject.  If  the  rachitic  process  is  complicated  by 
nervous  disorders,  it  is  frequently  fatal.  Sudden  death  in  eclampsia, 
tetany,  or  laryngismus  is  not  uncommon. 

The  prognosis  as  to  deformity  will  depend  on  the  severity  of  the 
affection.  Subsequent  treatment  will  not  always  correct  deformity 
of  the  pelvis  and  long  bones.  The  conditions  often  remain  perma- 
nent. Fortunately  rachitis  in  this  country  is  not  among  the  native 
born  of  so  severe  a  type  as  in  Germany,  Austria,  and  Switzerland. 
If  marked  hydrocephalus  is  a  complicating  condition,  the  prognosis 
is  bad. 

Treatment. — The  treatment  of  rachitis  differs  greatly  in  different 
countries,  but  there  are  certain  fixed  principles  upon  which  all  methods 
are  based.  Prophylaxis  is  an  important  element  in  all  methods.  An 
infant  at  the  breast  should  not  be  weaned  too  soon  if  the  breast  milk 
is  sufficient  in  quantity  and  the  infant  is  increasing  in  weight. 
Weaning  should  not  be  attempted  until  the  ninth  month.  If  it  is 
done  in  the  fall  or  winter,  the  milk  should  be  obtained  as  soon  as 
possible  after  the  time  of  milking.  There  is  no  need  of  sterilizing 
the  milk  if  it  has  been  collected  with  care.  It  is  at  most  pasteur- 
ized. Cows'  milk  should  be  diluted  so  that  the  fat  percentages  may 
be  low.  Beef -juice  if  well  borne  may  be  given  even  before  the  twelfth 
month  of  infancy.  At  the  eighteenth  month  meat  is  allowed  as  also 
vegetables,  especially  peas  and  spinach.  When  the  breast  milk  is 
insufficient,  it  should  be  supplemented  by  the  requisite  number  of 
artificial  feedings.  Rachitic  infants  do  better  on  two  breast-feedings 
a  day  with  several  artificial  feedings,  than  on  artificial  feeding  alone. 
Cows'  milk  is  the  substitute  for  the  breast.  It  should  be  properly 
prepared.  Many  severe  forms  of  rachitis  can  be  traced  to  the  use  of 
infant  foods. 

Artificially  fed  infants  should,  after  the  sixth  month,  be  allowed 
a  limited  amount  of  fresh  fruit  juice  once  a  day.  Orange  juice  is 
best,  but  cannot  be  borne  by  all  infants.     An  infant  should  not  be 


248  DISEASES  DUE  TO  DISTURBANCES  OF  NUTRITION. 

allowed  to  become  inordinately  constipated.  In  other  words,  treat- 
ment is  directed  toward  eliminating  all  predisposing  factors  to  the 
development  of  the  disease.  Some  breast-fed  infants  do  not  thrive. 
They  develop  serious  disturbances  of  nutrition  and  colic,  remain  sta- 
tionary in  weight,  and  have  irregular  and  green  curdy  movements. 
In  such  cases,  the  infant  should  be  weaned  in  part  from  the  breast  or 
given  another  wet-nurse.  Damp,  ill-ventilated  dwellings  predispose 
to  the  development  of  rachitis. 

Bathing.- — Young  infants  should  not  be  bathed  in  water  which  is 
much  below  the  temperature  of  the  body.  Such  bathing  prevents 
increase  in  weight  and  causes  disturbances  of  nutrition.  The  tem- 
perature of  the  bath  should  be  practically  the  same  throughout  in- 
fancy. An  infant  cannot  be  hardened  without  disturbing  metabo- 
lism. The  addition  of  sea  salt  to  the  bath  water  is  advised  by  some 
physicians,  and  brine  baths  are  in  general  use.  There  are  other 
kinds  of  baths  which  contain  iron,  but  I  have  had  no  experience  with 
them.  They  are  not  used  in  America,  but  are  in  vogue  in  European 
countries. 

Living  at  the  sea-coast  is  believed  to  exert  a  very  favorable  influ- 
ence upon  rachitic  infants  and  children.  On  the  other  hand,  if  there 
are  adenoids  or  affections  of  the  chest  and  lungs,  such  as  bronchitis 
of  a  chronic  variety,  the  humid  atmosphere  of  the  coast  is  not  likely 
to  be  beneficial,  and  mountain  resorts  are  better. 

Medicinal  Treatment. — Cod-liver  oil  has  long  been  a  favorite 
drug  in  the  treatment  of  rachitis.  It  should  be  given  in  the  emulsion 
with  the  hypophosphites  of  lime  and  soda.  An  infant  a  year  old 
should  take  half  a  teaspoonful  three  times  daily.  In  intestinal  dis- 
turbances, it  should  not  be  administered,  for  fear  of  aggravating  the 
symptoms.  The  external  application  of  the  pure  oil  to  the  body  can 
hardly  be  useful,  since  it  certainly  interferes  with  the  metabolism  of 
the  skin. 

Iron  in  the  form  of  the  hypophosphate,  grain  j  (0.06)  given  four 
times  a  day,  or  the  saccharated  carbonate,  grain  ij  (0.12)  three  times 
daily,  is  of  great  utility.  The  pomate  of  iron  or  the  more  digestible 
peptonates  of  iron  and  manganese  are  much  used.  The  combination 
of  thyroid  extract  and  iron  has,  in  some  cases  of  extreme  anaemia 
with  enlarged  spleen,  been  of  great  utility.  I  have  used  this  combi- 
nation only  in  cases  where  there  was  extreme  ansemia  with  rachitis : 

Thyroid  ext gr.  H0.03). 

Sacch.   carb.  iron gr.  5ij  (0.2).      (Heubner.) 

Tabes  pulv.  t.  i.  d. 

Henoch  has  advocated  the  use  of  thyroids  in  the  advanced  cases  of 
rachitis.  I  advise  the  cautious  use  of  thyroids  in  combination  with 
iron  in  selected  ambulatory  cases. 


BACHITIS.  249 

The  lactophosphate  of  lime  is  advised  by  some  authorities,  but 
is  of  little  value. 

It  has  been  shov^^n  by  Kassowitz  and  Wegner,  and  confirmed  by 
Virchow^,  that  in  the  lower  animals  phosphorus  administered  in  suffi- 
cient dosage  causes  an  increased  activity  in  the  processes  at  the 
epiphyseal  ossification  zone.  The  bone  becomes  more  compact,  but 
there  is  neither  an  increase  of  its  diameter  nor  deformity.  Kasso- 
vi^itz  has  contended  that  the  same  results  are  obtained  in  the  human 
subject.  On  this  question,  there  is  wide  difference  of  opinion.  Jacobi 
was  among  the  first  in  this  country  to  administer  phosphorus  as  a 
remedy  for  rachitis.  He  especially  advises  its  use  in  cases  of  cranio- 
tabes.  I  have  found  that  some  children  do  well  on  it,  while  in  others 
it  causes  gastric  and  intestinal  disturbances.  I  have  used  the  emul- 
sion of  lipanin,  so  much  recommended  by  Kassowitz,  as  a  vehicle  for 
the  phosphorus.  Enough  of  the  phosphorus  is  put  into  the  oil  to 
make  a  teaspoonful  of  the  emulsion  equal  to  Viao  grain  (0.00024). 
Thompson's  solution  of  phosphorus  may  also  be  used.  Preparations 
of  phosphorus,  even  those  made  with  oil,  deteriorate.  Kassowitz 
advises  the  formula  to  be  made  up  with  recently  dissolved  phosphorus. 

There  are  those  who,  like  Henoch,  Monti,  and  Heubner,  regard 
the  phosphorus  treatment  of  rachitis  with  distrust.  The  treatment 
of  rachitis  with  glandular  extracts  is  still  a  matter  of  empiricism. 
The  treatment  of  the  convulsions  of  laryngismus  will  be  discussed  in 
the  section  on  that  condition. 

Surgical  Treatment.- — It  is  not  within  the  scope  of  this  book  to 
dilate  on  the  surgical  or  orthopedic  management  of  rachitic  deformi- 
ties. It  is,  however,  proper  to  state  that  it  is  neither  right  nor 
necessary  to  place  every  infant  with  marked  spinal  curvature  due  to 
rachitis  in  a  plaster  jacket.  A  young  infant  with  marked  backward 
curvature  of  the  spine  will  gTadually  lose  this  deformity  as  its 
muscles  improve  in  tonicity,  but  if  placed  in  a  plaster  jacket  will 
probably  develop  a  subacute  bronchitis  or  pneumonia.  The  lung  is 
insufficiently  inflated  as  it  is,  and  becomes  much  more  so  if  the  soft 
thoracic  walls  and  abdomen  are  encased  in  a  plaster  cast.  In  such 
cases  the  sitting  posture  should  be  avoided.  The  infants  are  kept  in 
the  arms  or  sleep  on  an  ordinary  hair  mattress  without  a  pillow.  It 
is  not  possible  to  keep  them  in  any  particular  posture.  Massage  of 
the  spine  is  of  questionable  utility. 

Operations  for  the  correction  of  deformities  of  the  long  bones 
should  not  be  carried  out  until  the  rachitic  process  has  come  to  a 
standstill.  Surgeons  sometimes  advise  the  correction  of  deformities 
in  young  infants  by  encasing  the  limbs  in  j)laster  while  the  bones 
are  still  soft. 


250  DISEASES  DUE  TO  DISTUBBANCES  OF  NUTBITION. 

CHONDRODYSTROPHIA   FCETALIS. 

(So-called  Foetal  Eicl-ets;  Achondroplasia,  Micromelia.) 

Definition. — This  is  a  true  dystrophia  of  cartilaginous  growth  in 
the  long  bones,  resulting  in  deformities  which  consist  in  a  shortening 
of  the  extremities  and  certain  changes  in  the  bony  structure  of  the 
head.  Cases  of  this  rare  condition  have  been  reported  in  this  country 
by  Jacobi,  Smith,  Herrman,  and  Townsend.  Thomson,  of  Edin- 
burgh, has  described  the  affection  as  of  intra-uterine  origin.  Although 
Horsley  and  Barlow  classify  these  cases  wnth  sporadic  cretinism,  they 
have  nothing  in  common  either  with  cretinism  or  rachitis,  and  must 
be  regarded  as  a  distinct  pathological  entity.  The  patients  are  far 
from  being  idiotic  or  presenting  any  of  the  symptoms  of  myxoedema. 
The  case  published  by  Townsend  was  that  of  a  still-born,  infant. 
Parrot  and  Jacobi  have  described  infantile  cases. 

Forms. — From  a  pathological  standpoint  there  are  three  forms  of 
this  affection:  The  first  is  that  in  which  there  is  a  softening  of  the 
primordial  cartilage,  or  so-called  chondromalacia  foetalis ;  second,  that 
in  which  there  is  a  cessation  of  gi-o^vth  of  cartilage,  so-called  chondro- 
dystrophia  hypoplastica ;  and  lastly,  the  form  in  which  there  is  an 
increased  but  very  irregTilar  growth  of  the  cartilaginous  part  of  the 
long  bones,  so-called  chondrodystroj)hia  hyperplastica.  In  all  of  these 
forms  the  resulting  deformities  are  characteristic.  They  are  as 
follows : 

(a)  The  skull  has  a  peculiar  form,  the  vertex  is  large.  The  root 
of  the  nose  in  one  set  of  cases  is  sunken;  in  another  set  the  whole 
nose  is  flattened.  In  both  sets  of  cases  a  peculiar  expression  is  given 
to  the  face,  which  at  first  was  mistaken  for  cretinoid.  The  form  of 
the  skull  was  thought  by  Yirchow  to  be  due  to  a  premature  synostosis 
of  the  three  bones  comprising  the  tribasilar  bone ;  this  has  since  been 
disproved,  being  true  of  only  one  set  of  cases ;  in  some  cases  the  whole 
tribasilar  bone  is  cartilaginous,  and  in  others  there  is  no  synchondro- 
sis, nor  even  a  marked  shortening  or  premature  synchondrosis.  The 
changes  in  the  skull  are  of  the  same  nature  as  those  in  the  long  bones, 
viz.,  dystrophic. 

(&)  The  long  bones  in  the  most  characteristic  types  are  shortened. 
The  diaphysis  is  short  and  thick,  so  as  to  present  little  or  no  medul- 
lary canal;  the  epiphyses  are  mostly  cartilaginous  and  enlarged,  and 
the  whole  bone  is  bent,  the  normal  curve  being  exaggerated.  The 
picture  thus  presented  is  that  of  a  dwarf  with  short  extremities 
(micromelia).  There  are  forms  of  chondrodystrophia  without  any 
marked  shortening  of  the  extremities,  but  rather  of  the  lower  part 
of  the  trunk  (Klebs,  Kaufmann). 

Morbid  Anatomy. — There  are  no  changes  in  any  of  the  internal 


PLATE   XI 


Chondrodystrophia    Foetalis,  or  Achondroplasia. 


A — Infant,  aged  nine  months. 
B — Child,  aged  three  years. 


CHONDRODYSTBOPHIA  FCETALIS.  251 

organs.  The  parts  at  the  base  of  the  brain,  the  pons,  may  extend 
above  the  sella  turcica  in  an  upward  instead  of  a  forward  direction. 
This  is  due  to  the  peculiar  changes  present  at  the  base  of  the  skull. 
The  pituitary  body  is  normal.  The  thyroid  shows  no  marked  changes. 
The  flat  bones  are  normal ;  but  in  the  bones  which  are  formed  from 
cartilage,  the  so-called  endochondral  ossification  is  disturbed.  These 
bones,  such  as  the  sternum,  patella,  and  costal  cartilages,  the  tarsal 
and  metacarpal  bones,  show  changes.  The  long  bones  present  endo- 
chondral disturbances ;  there  is  an  absence  of  the  long  lines  of  car- 
tilaginous cells,  and  at  the  ossification  zone  there  is  a  most  irregular 
proliferation  of  cartilage-cells  and  ossification.  It  is  thus  that  the 
growth  of  the  long  bones,  of  the  innominata,  and  of  the  bones  at  the 
base  of  the  skull  are  disturbed.  The  vertebral  column  may  be 
normal,  or  the  antero-posterior  diameter  of  the  vertebrae  may  be 
shortened.  The  thorax  is  small  and  flat,  due  to  arrested  development 
of  the  ribs.  On  section  the  bones  present  no  parallel  rows  of  cartilage- 
cells,  no  medullary  spaces,  no  projection  of  medullary  bloodvessels 
into  the  cartilage.  There  is  an  absence  of  vessels  at  the  ossifying 
junction,  the  bone  being  formed  mainly  from  the  periosteum.  The 
heads  of  the  bones  are  thus  chiefly  made  up  of  hyaline  cartilage ;  the 
shaft  of  the  bone  of  periosteal  bone-formation. 

From  the  above  data  of  the  morbid  anatomy  in  this  disease  it 
can  be  seen  why  this  condition  has  nothing  in  common  with  rachitis 
and  cretinism,  and  should  not  be  called  foetal  rickets  or  "  so-called  " 
foital  rachitis. 

Symptoms. — The  general  picture  is  that  of  a  dwarf  Math  short 
extremities  and  a  body  trunk  of  normal  length.  The  four  extremi- 
ties are  affected.  The  arms  are  shorter  than  the  forearms,  the  thighs 
than  the  legs.  The  head  is  large,  at  times  assuming  a  hydroceph- 
alic contour,  the  parietal  and  frontal  bones  are  prominent,  the  root 
of  the  nose  is  broad,  the  bridge  depressed,  the  tip  large  and  the  nos- 
trils open,  the  features  are  large  and  heavy.  The  vault  of  the  palate 
is  high.  The  lumbar  curve  of  the  spine  forward  is  much  exagger- 
ated, the  sacrum  thrown  back,  causing  in  the  female  a  narrowing  of 
the  brim.  The  hips  are  large  and  muscular,  as  also  the  muscles  of 
the  extremities  and  trunk.  The  lower  extremities  are  bowed  and 
the  legs  are  articulated  at  an  angle  with  the  thigh.  The  hands  are 
square,  massive,  reduced  in  all  proportions,  the  fingers  of  equal 
length,  thus  giving,  when  spread,  the  appearance  of  a  trident.  The 
intelligence  is  very  good;  in  some  cases  the  subjects  may  not  be  as 
bright  as  the  normal  individuals. 

Diagnosis. — A  differential  diagnosis  must  be  made  from  Rachitis, 
Cretinism,  Infantilism,  and  Osteogenesis  imperfecta.  A  careful 
study  of  the   symptomatology  will   show  quite   distinctly  that   the 


252  DISEASES  DUE  TO  DISTUBBANCES  OF  NUTBITION. 

characteristics  of  each  of  tliese  conditions  cannot  be  mistaken  for 
each  other. 

Prognosis  and  History. — Many  of  these  cases  die  at  birth,  but 
many  attain  adult  life  and  are  of  good  intelligence,  though  some  cases 
may  have  less  than  the  normal  intelligence.  They  may  have  children. 
The  children  of  the  female  sex  may  have  chondrodystrophia ;  though 
among  the  handsomest  that  I  have  ever  seen  were  the  offspring  of  a 
female  chondrodystrophic  dv^arf,  whose  children  were  patients  in  my 
clinic.  This  dwarf  had  little  difficulty  in  labor,  though  in  some  cases 
this  difficulty  may  be  present.  Her  children  presented  absolutely  no 
deformities,  but  were  brought  for  treatment  for  the  slight  disturb- 
ances of  infancy  and  childhood. 

OSTEOGENESIS  IMPERFECTA. 

(Fragilitas  Ossium  IdiopatMca.) 

This  is  a  systemic  disease  of  the  bones  which  attacks  the  young 
foetus,  and,  without  causing  appreciable  abnormalities  in  other  organs, 
prevents  or  disturbs  the  normal  development  and  calcification  of  osteoid 
tissue.  The  disease  manifests  itself  by  defective  development  of  the 
cranial  bones,  with  fragility  of  the  entire  osseous  skeleton.  Cases  of 
this  nature  have  been  reported  in  the  foetus  or  in  the  newborn  infant — 
born  dead  or  dying  within  a  short  time  after  birth ;  recently,  how- 
ever, cases  have  appeared  in  the  literature  which  have  lived  to  adoles- 
cence with  all  the  symptoms  of  the  affection. 

Morbid  Anatomy. — The  examination  of  the  bones  after  their  re- 
moval from  the  body  shows  them  to  be  delicate  and  fragile,  fracturing 
with  the  slightest  force.  At  times  the  periosteal  bone  shell  is  so 
thin  that  it  may  be  crushed  between  the  fingers  with  very  little  force. 
Sections  of  the  bones  show  them  to  be  porous,  the  trabeculse  delicate, 
the  outer  layer  exceedingly  thin,  there  being  no  dense  bone,  but  a 
collection  of  small  plates  and  trabeculse.  Calcification  of  the  osteoid 
tissue  is  defective  or  entirely  absent  in  places.  The  epiphyseal  car- 
tilages are  normal,  both  in  size  and  consistence.  Microscopically,  it 
is  revealed  that  the  process  is  confined  entirely  to  the  shaft  of  the 
bone,  where  the  normal  development  and  calcification  of  osteoid  tissue 
is  lacking.  The  formation  of  rows  and  their  subsequent  calcification 
and  disintegration  go  on  in  a  normal  manner.  It  is  at  the  stage  of 
true  bone-formation  that  the  disease  is  manifest.  The  osteoblasts  are 
diminished  in  numbers  and  deposit  only  a  thin  layer  of  osseous  tissue. 
Calcification  is  thus  delayed,  deficient,  or  entirely  absent.  The 
other  organs  of  the  body  are  entirely  normal. 

Symptoms.— The  general  appearance  of  the  newborn  infant  with 
osteogenesis  imperfecta  is  characteristic.     The  skin  and  the  subcu- 


OSTEOGENESIS  FCETALIS.  253 

taneous  tissue  may  be  thickened ;  on  the  other  hand,  they  may  be 
quite  normal.  The  extremities  are  not  shortened  as  the  result  of  the 
cessation  or  retardation  of  growth,  but  are  bent  and  deformed  and 
may  be  the  seat  of  multiple  fractures.  The  ribs  may  be  the  seat  of 
fracture.  Some  of  these  fractures  may  have  united  in  utero,  in 
which  event  we  have  the  resulting  deformity.  Fractures  may  be  so 
numerous  as  to  give  the  long  bones  a  nodular  appearance.  All  the 
bones  of  the  body  partake  of  this  fragility.  The  spinal  column  is 
soft  and  fragile,  presenting  anteroposterior  and  lateral  deviations. 
The  ribs  may  be  fractured  to  an  excessive  degree.  In  Merkel's  case 
no  less  than  forty-three  fractures  were  present.  The  clavicle  shows 
fractures  very  similar  to  what  is  seen  in  cases  of  rachitis.  The 
cranial  bones  show  defective  ossification,  as  is  evidenced  by  the  widely 
open  sutures,  or  the  cranial  vault  may  consist  simply  of  a  mem- 
branous sac. 

The  slightest  traumatism,  such  as  a  jar  against  some  object,  may 
produce  these  fractures.  They  occur  soon  after  birth  and  may  be 
present,  though  unsuspected,  when  the  child  is  born.  When  born, 
children  are  carefully  handled,  for  which  reason  fractures  are  not  so 
likely  to  be  observed  at  this  time ;  as  soon,  however,  as  the  children  are 
allowed  more  liberty  of  motion  fractures  occur.  They  are  attended 
with  less  pain  and  inflammation  than  in  the  normal  individual,  due, 
no  doubt,  to  the  slight  traumatism.  Union  takes  place  rapidly  and  is 
usually  firm.  In  some  cases  complete  fracture  does  not  occur,  but 
infraction,  resembling  in  a  general  way  what  is  seen  in  rachitis. 
Some  individuals  not  only  survive  childhood  and  learn  to  walk  but 
may  attain  adolescence  suffering  from  this  disease. 

Differential  Diagnosis. — Differential  diagnosis  must  be  made  from 
chondrodystrophia  foetalis.  In  the  latter  disease  the  prognathous 
expression  of  the  face  is  characteristic,  with  flattening  of  the  nasal 
region;  the  bones,  though  shortened,  are  dense  and  hard,  and,  aside 
from  slight  bowing  of  the  legs,  are  not  deformed.  In  later  life  the 
chondrodystrophic  individual  is  a  dwarf,  with  shortened  extremities 
and  no  predisposition  of  the  bones  to  fracture. 

Osteogenesis  imperfecta  is  differentiated  from  rachitis  by  the  ab- 
sence of  the  rib  rosary,  the  enlarged  epiphyses,  and  other  states  char- 
acteristic of  the  disease.  We  can  scarcely  confound  this  disease  with 
hereditary  syphilis,  or  sarcoma  or  any  new  growth  of  the  bone,  or 
osteomyelitis.  The  dystrophy  of  syphilis  is  so  characteristic  as  to 
bear  no  resemblance  to  the  disease  just  described,  the  chief  charac- 
teristics of  which  are  fragility  of  the  bones  associated  with  defective 
ossification  of  the  cranial  bones. 

Etiology. — The  etiology  of  this  disease  is  as  yet  a  matter  of 
speculation. 


254  DISEASES  DUE  TO  DISTUSBAXCES  OF  NUTEITION. 

Treatment. — Its  treatment  must  be  founded  on  general  indications, 
increasing  the  strength  of  the  patient  and  protecting  the  bones  from 
fracture. 

INFANTILE    SCORBUTUS   OR    SCURVY    (Barlow). 

(Acute  Sachitis    (Moller)  ;   Barlow's   Disease,   Hemorrliagic  JRachitis    (Furst)  ; 
Scurvy  Bicl-ets   (Cheadle)  ;  Hemorrhagic  Periostitis   (Smith).) 

History. — Cases  of  this  affection  are  described  in  the  earlr  litera- 
ture under  the  name  Acute  Rachitis,  given  to  it  bj  Moller,  1859— 
1862.  The  first  definite  clinical  description  of  the  disease  under  its 
present  title  was  made  by  Barlow.  Cheadle,  Gee,  and  others  of  the 
English  school,  completed  its  clinical  study.  ISTorthrup  and  Crandall 
have  made  it  familiar  to  American  physicians. 

Occurrence. — The  disease  occurs  chiefly  in  infants  and  in  chil- 
dren under  the  age  of  two  years.  Under  certain  conditions  it  also 
occurs  in  older  children  and  in  adults.  The  majority  of  the  372 
cases  collected  by  the  committee  of  the  American  Pediatric  Society, 
occurred  between  the  sixth  and  fourteenth  months.  The  ninth  month 
showed  the  greatest  percentage  of  the  cases  occurring  before  the  end 
of  the  second  year.  The  sexes,  were  equally  affected.  A  second 
attack  was  recorded  in  a  ease  of  Holt's.  In  one  of  my  cases  there 
were  two  attacks. 

The  Nature  of  the  Affection. — The  nature  of  scurvy  as  it  is  seen 
in  infants  and  children  is  still  obscure.  It  is  undoubtedly  a  form  of 
hemorrhagic  diathesis,  which  attacks  subjects  susceptible  because  of 
previous  abnormal  constitutional  conditions  and  defective  nutrition. 
There  are  several  theories  as  to  its  exact  nature.  J^one  is  universally 
accepted.  Some  insist  that  it  is  a  form  of  acute  rachitis  (Moller, 
Forster,  Bohm,  Steiner,  Fiirst,  Ausset).  Others  contend  that  it  is  a 
form  of  scorbutus  (Barlow,  ITorthrup,  Crandall,  ]Sretter,  Rehn,  Pott). 
Some  of  the  English  school  regard  it  as  a  combination  of  scurvy  and 
rickets  (Cheadle,  Cee,  West).  To  the  latter  contention  Heubner, 
Schoedel,  and  jSTauwerck  give  most  support.  These  authors  insist 
that  the  disease  supervenes  only  in  an  organism  already  affected  by 
slio-ht  or  marked  rachitis.  On  the  other  hand,  Schmorl  and  ITaeffeli 
think  that  the  affection  is  siii  generis.  Some  have  endeavored  to 
establish  a  correlation  with  congenital  syphilis.  The  consensus  of 
clinical  oi)inion,  however,  tends  toward  the  acceptance  of  the  theory 
of  the  scorbutic  nature  of  the  affection  and  its  close  connection  with 
disturbances  of  nutrition. 

Etiology. — The  essential  exciting  cause  is  not  yet  known.  The 
theory  of  the  tox?emic  or  infectious  nature  of  the  disease  has  been 
advocated  by  William  Koch.     Bacteria  of  various  kinds  have  been 


INFANTILE  SCORBUTUS  OB  SCURVY.  255 

found  in  the  blood,  bnt  there  is  little  uniformity  in  the  results  of  these 
studies.  In  all  the  cases  thus  far  studied  the  nature  of  the  diet, 
breast-milk,  raw  cows'  milk,  sterilized  or  pasteurized  milk,  or  some 
artificial  food,  has  been  a  strong  predisposing  factor.  The  diet  has 
been  insufficient  for  the  nutrition  of  the  patient,  but  what  special 
element  has  been  lacking  in  the  food  is  still  obscure.  In  the  collected 
results  of  the  investigations  of  the  American  Pediatric  Society  10 
infants  were  wholly  breast-fed ;  2  were  partially  breast-fed ;  4  took 
raw  milk.  The  greater  number,  68,  were  brought  up  exclusively  on 
sterilized  milk;  16  took  Pasteurized  milk.  The  others  took  foods  of 
different  kinds.  It  may  be  that  the  mode  of  preparing  the  food 
(raw  cows'  milk,  Pasteurized  or  sterilized  milk)  is  of  less  importance 
in  paving  the  way  for  the  onset  of  this  affection  than  its  inherent 
composition.  Cases  have  been  cured  in  part  by  changing  the  compo- 
sition of  the  food,  also  by  substituting  sterilized  for  pasteurized  food, 
and  vice  versa.  The  very  fact  that  breast-milk  has  been  the  exclusive 
article  of  diet  in  some  cases  should  direct  attention  to  the  fact  that 
the  affection  may  be  caused  by  lack  of  some  necessary  element  in  the 
food.     This  view  is  commonly  accepted  at  present. 

It  is  interesting  in  this  connection  to  consider  the  contention  of 
the  celebrated  Arctic  explorer  ISTansen,  that  with  exercise  and  fresh 
air,  and  abstinence  from  alcohol,  scurvy  on  voyages  will  be  unknown 
if  foods  are  carefully  sterilized  and  devoid  of  toxins  and  ptomains. 
The  latter,  he  insists,  exist  in  most  of  the  milk,  fish,  and  food  eaten 
on  voyages.  Although  in  the  most  aggravated  cases  of  scurvy  that 
have  come  under  my  notice  the  diet  has  been  sterilized  milk,  many 
infants  who  take  that  food  prepared  properly  do  not  develop  the  dis- 
ease. Some  authors  believe  that  the  success  of  antiscorbutic  treat- 
ment with  vegetable  acids  indicates  that  the  organism  has  been  for  a 
time  deprived  of  some  essential  food  element.  In  the  presence  of  a 
concrete  case  attention  should  first  be  directed  to  securing  fresh  food 
of  proper  composition. 

In  one  of  my  cases  a  good  raw  milk  was  the  food,  but  it  contained 
7  per  cent,  of  fat.  In  another  case  the  infant  was  at  the  breast,  the 
milk  of  which  contained  only  .7  per  cent,  of  fat ;  both  of  these  foods 
on  the  face  of  it  were  denutritional. 

Rachitis. — Much  has  been  said  as  to  the  connection  of  rachitis 
with  this  disease.  The  investigations  above  referred  to  show  that 
fully  45  per  cent,  of  the  cases  occurred  in  infants  and  children  who 
showed  clinically  signs  of  rachitis.  This  does  not  account  for  cases 
in  which  rachitis  may  exist,  but  may  not  be  apparent  except  on 
microscopic  examination  (Hirschsprung,  Schoedel).  The  majority 
of  cases  examined  post  mortem  showed  the  changes  of  rachitis 
(Schoedel,  Schmorl). 


256  DISEASES  DUE  TO  DISTURBANCES  OF  NUTRITION. 

Morbid  Anatomy. — The  morbid  anatomy  has  been  carefuUr  and 
extensively  studied  by  Schoedel,  ISTanwerck,  and  Sekmorl,  whose  re- 
sults agree  in  all  essentials. 

Bones. — The  bones  in  most  cases  show  the  changes  seen  in  rachitis. 
There  are  disturbances  of  growth  and  of  bone  formation.  There  is 
an  increase  in  the  width  and  vascularization  of  the  cartilage  zone. 
There  are  irregularity  of  the  calcification  zone,  and  a  pathological 
formation  of  osteoid  tissue.  The  changes  at  the  epiphyseal  junction 
and  the  periosteum  are  those  seen  in  rachitis.  The  ribs  are  the  bones 
most  frequently  affected,  the  next  greatest  frequency  being  in  the 
bones  of  the  lower  and  uj^j^er  extremities.  The  changes  caused  by 
scurvy  consist  of  hemorrhages  into  the  loose  vascular  layer  of  con- 
nective tissue  of  the  periosteum  adjacent  to  the  bone.  Thus  the 
hemorrhages  are  intraperiosteal  and  subperiosteal  (Plate  XII.). 
They  may  be  of  considerable  extent,  either  in  the  vicinity  of  the 
epiphyseal  junction  or  in  course  of  the  shaft  of  the  bone.  They  may 
form  a  layer  several  millimetres  or  centimetres  in  thickness.  The 
outer  layer  of  the  periosteum,  the  fibrillar  connective-tissue  strata,  is 
not  the  seat  of  hemorrhage  except  in  the  severest  cases.  The  layer 
of  periosteum  next  the  bone  is  thickened.  The  hemorrhages  are  both 
recent  and  old.  Hemorrhages  of  both  kinds  are  found  in  the  medul- 
lary canal.  The  morbid  changes  are  most  marked  in  the  ribs,  next  in 
the  femur  and  in  the  bones  of  the  upper  extremities.  Some  of  the 
long  bones  show  loosening  and  even  separation  of  the  epiphyses  and 
diaphyses.  The  infractures  or  fractures  are  of  this  nature.  The 
frag-ments  may  override.  In  such  cases  the  hemorrhage  is  great. 
The  marrow  of  the  bones  loses  its  lymphoid  character  and  becomes 
gelatinous. 

There  are  subpleural  and  subepicardial  hemorrhages.  The  spleen 
is  enlarged,  owing  to  the  presence  of  rachitis.  Slight  subcutaneous 
hemorrhages  may  extend  into  the  muscular  tissue.  There  are  hemor- 
rhages into  the  mucous  membrane  of  the  hard  palate  and  gums. 

Symptoms. — Mild  cases  sometimes  escape  notice.  An  ansemic 
infant  may  cry  when  bathed  or  may  favor  one  extremity.  It  may 
hold  one  thigh  rigid  or  cry  when  the  limb  is  handled  in  the  process 
of  diapering.  Mothers  at  first  suspect  traumatism.  The  infant 
develops  slight  ecchymoses  on  the  tibicP.  and  is  then  brought  to  the 
physician.  If  there  are  teeth,  there  may  at  this  stage  be  no  swelling 
of  the  gums  or  of  the  extremities.  Along  the  border  of  the  gums 
there  is  a  very  thin  blue  line.  There  is  no  fever ;  there  may  not  be 
any  anspmia.  In  some  of  my  very  early  cases,  in  addition  to  tender- 
ness of  the  bones,  there  was  hsematuria.  In  the  severer  cases  the 
sjonptoms  are  more  marked.  The  skin  in  the  infant  of  from  seven 
to  nine  months  of  age  acquires  a  pallid  or  greenish  tinge.  The  infant 
cries  when  touched. 


PLATE   XII 


X-ray  of  the  Bones  of  the  Leg  in  a  Case  of  Scorbutus, 
sho"wing  the  hemorrhage  under  and  in  the  periosteum  of 
the  tibia  at  the  junction  of  the  middle  and  lower  third  of 
the  bone. 


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INFANTILE  SCOEBUTUS  OB  SCURVY.  257 

One  or  both  of  the  lower  extremities  lies  as  if  paralyzed.  If  an 
attempt  is  made  to  move  them,  the  infant  appears  to  feel  pain.  The 
limb  is  swollen  in  the  course  of  the  shaft  or  in  the  vicinity  of  the 
knee  or  ankle,  the  swelling  extending  up  the  shaft  (Plate  XIII.), 
The  ribs  are  apparently  tender.  There  may  be  one  or  two  subcu- 
taneous ecchymoses  on  the  surface  of  the  body.  If  there  are  teeth, 
the  gums,  especially  those  of  the  upper  jaw,  are  swollen  into  cushion- 
like formations.  These  bleed  easily  and  may  partly  conceal  the  teeth. 
If  there  are  no  teeth,  the  gums  may  appear  normal,  or  the  free  bor- 
der, especially  of  those  of  the  upper  jaw,  may  have  a  bluish,  swollen 
appearance,  which  may  be  very  slight  or  quite  marked.  There  may 
be  a  small  hemorrhage  into  the  sac  of  the  tooth  which  may  not  yet 
have  erupted.  The  infants  may  have  a  capricious  appetite,  may  take 
little  of  the  bottle  or  may  nurse  ravenously. 

The  very  severe  cases  have,  as  a  rule,  been  allowed  to  run  on  for 
months  in  the  belief  that  the  infants  were  suffering  either  from  rheu- 
matism or  dropsy.  For  some  time  before  coming  under  treatment, 
the  infant  has  cried  when  diapered  or  when  the  shoes  or  stockings 
were  put  on;  later  it  becomes  pale  and  loses  ground.  The  appetite 
is  poor.  The  thighs  and  the  ankles  begin  to  swell.  The  child  does 
not  move  the  extremities,  which  are  swollen  to  twice  or  three  times 
the  original  circumference.  Ecchymoses  appear  on  the  surface  of 
the  swellings  of  the  legs  and  thighs.  Parts  of  the  skin  acquire  a 
bluish-green,  bruised  appearance.  Deformity  occurs  in  the  thigh, 
especially  at  the  junction  of  the  diaphysis  with  the  head  of  the  bones. 
This  is  due  to  infracture  or  loosening  of  the  epiphyses  at  the  epiphy- 
seal line.  The  costochondral  junction  of  the  ribs  is  much  swollen. 
There  is  a  distinct  series  of  very  large  swellings  in  this  locality  which 
are  due  to  hemorrhage  into  the  line  of  juncture  of  the  rib  and  carti- 
lage. Ecchymoses  and  sugillation  appear  about  the  orbit.  The  face 
and  eyes  have  an  (Edematous,  hydrsemic  appearance.  The  gums  may 
not  be  at  all  affected,  but  if  the  infant  has  teeth  there  may  be  spongi- 
ness  and  bluish  discoloration  of  the  gums. 

When  the  infant  is  examined,  the  pain  produced  by  the  procedure 
causes  it  to  shriek  with  agony.  The  ribs  are  painful  to  the  touch. 
The  swellings  on  the  thigh  are  uniformly  fusiform,  and,  as  a  rule, 
hard  and  not  fluctuating.  The  abdomen  is  tense  and  tympanitic. 
There  may  be  some  bleeding  from  the  nose,  but  not  necessarily  from 
the  bowel.  In  other  cases  there  are  not  only  hemorrhages  from  the 
bowels,  but  also  from  the  kidney,  in  the  form  of  hsematuria.  There 
may  be  albumin  and  casts  in  the  urine,  or  these  may  be  absent. 

Of  especial  interest  are  those  cases  in  which  hsematuria  is  the 
only  marked  objective  symptom  of  the  disease.  Such  cases  as  I  have 
seen  were  in  excellent  physical  condition,  of  good  weight  and  color, 

17 


258 


DISEASES  DUE  TO  DISTUBBANCES  OF  NUTBITION. 


and  still  for  a  period  of  days  or  weeks  have  voided  urine  which  con- 
tains blood,  but  no  casts.  Careful  examination  will  reveal  a  tender- 
ness of  the  tibiae,  or  a  just  perceivable  swelling  of  the  gums  or  a  very 
narrow  blue  line  along  the  gums.  I  have  recently  seen  a  number  of 
cases  of  scorbutus  in  which  the  main  symptom  was  the  appearance  of 
blood  in  the  stools,  simulating  a  dysentery.  In  another  case,  that  of 
a  child  twenty-two  months  of  age,  the  first  symptom  of  scorbutus  was 
a  sharp  hemorrhage  from  the  bowel.  This  hemorrhage  was  repeated, 
but  was  not  as  profuse  as  the  initial  one.  A  careful  examination  in 
this  case  revealed  a  slight  tenderness  of  the  tibiae  and  a  tendency  to 
ecchymoses  following  the  least  traumatism. 

Fig.  33. 


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Temperature-curve  of  a  case  of  scorbutus  in  an  infant  seven  months  of  age.  Resorp- 
tion fever.  The  chart  shows  the  very  high  number  of  respirations  as  compared  to  the 
pulse.  Cause  of  high  respirations  probably  pain  and  extreme  ansemia.  The  curve  taken 
from  the  start  of  treatment. 


The  pulse  is,  as  a  rule,  not  increased  in  frequency.  In  one  case 
without  complicating  pneumonia,  in  which  I  found  the  respirations 
enormously  increased,  I  reached  the  conclusion  that  this  increase  was 
due  to  the  pain  and  extreme  anaemia. 

In  severe  cases  there  may  be  slight  temperature  (Fig.  33),  due  to 
resorptive  fever  caused  by  the  immense  extravasations  of  blood. 

The  hemorrhages  in  the  skin  may  be  localized  in  the  form  of 
minute  petechia  or  there  may  be  ecchymotic  blotches  of  considerable 
size.     The  latter  may  appear  over  the  swellings  along  the  bones. 

The  fractures  or  infractions  were  present  in  only  9  cases  of  the 
set  collected  by  the  American  Pediatric  Society.  The  gums  were 
generally  affected  in  infants  with  teeth,  and  were  swollen  and  spongy 
in  24  cases  in  which  there  were  no  teeth.  They  may  be  normal  in 
severe  cases  if  there  were  no  teeth,  and  swollen  in  mild  ones.  The 
symptoms  in  older  children  resemble  those  of  adults.  In  one  case 
in  a  child  over  two  years  of  age  the  surgeons  of  a  dental  clinic  had 


INFANTILE  SCOBBUTUS  OS  SCUEVY.  259 

been  consulted  for  an  uncontrollable  bleeding  of  the  gums.  The 
child  had  ceased  to  walk  on  account  of  pains  in  the  lower  extremities, 
which  had  been  interpreted  as  rheumatic.  In  older  children  the 
gums  are  affected,  and  the  hemorrhages  take  the  form  of  petechise 
and  blotches,  appearing  in  crops  over  the  surface  of  the  body  as  in 
the  adult.     They  have  joint-pains  and  malaise. 

Prognosis. — The  disease  in  infants  and  children  gives  a  very  good 
prognosis  if  recognized  and  treated  in  time.  Most  cases  recover. 
The  fatal  cases  are  those  in  institutions  or  elsewhere  in  which  the 
diagnosis  has  not  been  made  or  in  which  death  has  been  caused  by 
some  intercurrent  affection,  such  as  cerebral  hemorrhage,  diarrhoea, 
or  pneumonia.  In  379  cases  collected  by  the  American  Pediatric 
Society  the  mortality  was  8  per  cent.  It  would  seem  to-day  that  with 
improved  methods  this  figure  should  be  much  lower. 

Duration.^ — There  is  no  fixed  duration.  Much  depends  on  an 
early  diagnosis.  Even  if  the  disease  has  existed  months  before  a 
diagnosis  is  made,  the  patient  may  still  recover.  The  great  danger 
is  that  a  hemorrhage  may  occur  in  the  cerebrum  or  that  the  infant 
may  contract  an  intercurrent  affection  through  exhaustion.  If  allowed 
to  continue  without  treatment,  the  disease  may  cause  exhausting  intes- 
tinal hemorrhages  or  hemorrhage  of  great  extent  elsewhere,  Math  con- 
sequent anaemia  and  death. 

Diagnosis. — The  diagnosis  of  infantile  scurvy  presents  no  diflicul- 
ties.  The  pains  in  the  extremities,  the  paralytic  phenomena,  the 
swelling  of  the  gums,  the  swelling  in  the  vicinity  of  the  joints  of  the 
limbs,  or  along  the  shafts  of  the  bones,  the  swellings  on  the  ribs,  and 
the  ecchymoses  in  the  skin  and  about  the  eye,  are  all  characteristic. 
The  pareses  of  the  upper  extremity  are  frequently  mistaken  for  those 
due  to  syphilis.  The  history,  and  the  absence  of  syphilitic  eruptions 
will  aid  in  diagnosis.  In  the  presence  of  a  hsematuria  in  an  artifi- 
cially-fed infant,  where  other  causal  elements  fail  we  should  always 
think  of  the  possibility  of  scurvy.  In  cases  of  prolonged  enteric 
catarrh,  in  which  the  infants  are  emaciated  and  pass  pure  blood  with 
the  movements,  scurvy  should  be  thought  of.  I  have  seen  a  case  of 
scurvy  with  hemorrhages  from  the  bowel  mistaken  for  intussuscep- 
tion, and  operated  under  this  mistaken  diagnosis. 

Treatment. — The  treatment  of  infantile  scurvy  is  simple  and  sat- 
isfactory. The  infant  is  given  fresh  milk  properly  modified.  The 
milk  should  be  given  raw,  and  in  summer  should  be  kept  well  packed 
in  ice.  In  addition,  orange-juice  and  lemonade  are  given  in  the 
course  of  the  day.  An  infant  seven  months  old  should  have  2  ounces 
of  lemonade  and  one  ounce  of  orange-juice  in  twenty-four  hours,  given 
every  two  hours  after  each  nursing.  Some  authors  advise  the  giving 
of  beef-juice,  but  it  is  necessary  only  when  fruit  juices  are  not  toler- 


260  DISEASES  DUE  TO  DISTURBANCES  OF  NUTRITION. 

ated.  After  two  weeks  the  quantity  of  fruit  juice  should  be  reduced, 
but  a  small  quantity  of  orange-juice  should  be  given  daily  for  some 
time.  Medicines  are  not  indicated  except  for  the  anaemia,  which  is 
best  treated  by  doses  of  half  a  drop  of  Fowler's  solution  given  three 
times  daily,  or  by  some  easily  assimilable  peptonate  of  iron. 

MARASMUS  OR  INFANTILE  ATROPHY. 

(Athrepsia  (Parrot).) 

Definition. — Infantile  atrophy  or  marasmus  is  a  condition  due  to  a 
distinct  disturbance  of  nutrition  traceable  to  the  food  of  the  infant  in 
the  absence  of  any  infectious  or  bacterial  agent. 

Occurrence. — It  is  seen  in  infants  both  of  the  wealthy  class  and 
among  the  poor.  In  both  cases  the  infants  have  been  improperly 
fed  and  in  breast-fed  infants  the  same  results  follow  as  in  bottle-fed 
infants  if  the  breast-milk  is  inefficient.  Secondarily  it  may  follow 
any  disease  of  the  gut  or  complicate  syphilis  or  prematurity,  but  these 
cases  are  not  properly  included  under  the  heading  of  primary  atrophy. 

Etiology. — The  cause  of  atrophy  is  now  quite  well  understood.  It 
is  not  the  result  of  any  infection  but  is  the  cumulative  result  of  the 
inefficiency  of  the  food  in  sustaining  the  nutrition.  The  elements  of 
the  food  to  which  in  past  years  most  attention  and  study  have  been 
directed,  especially  in  bottle-fed  infants,  are  the  fats,  proteids,  and 
carbohydrates  or  sugar.  Formerly  the  proteids  of  cows'  milk  were 
thought  to  work  great  injury  to  the  infant  and  those  who  did  not 
thrive  and  finally  developed  the  symptom  complex  of  atrophy  were 
thought  to  have  fallen  victims  to  the  great  difficulty  of  assimilation 
of  the  proteids.  The  casein  of  cows'  milk,  it  was  argued,  coagulated 
in  the  stomach  in  thick  leathery  curds  and  the  energy  expended  by 
the  stomach  and  intestine  in  assimilating  and  especially  preparing 
these  curds  for  assimilation  wore  out  the  infant  and  appropriated 
energy  to  the  loss  of  body-weight. 

Heubner  and  Rubner  especially  were  active  in  maintaining  this 
theory.  To-day  we  are  not  so  certain  that  this  is  really  so  or  that 
the  casein  of  cows'  milk  is  so  much  more  difficult  of  digestion  than 
that  of  mother's  milk.  Some  maintain  (Meyer)  that  the  difficulty 
lies,  not  in  the  rough  curding  of  the  casein  of  cows'  milk,  but  in  the 
inability  of  some  infants  to  convert  the  foreign  proteid  of  cows'  milk 
into  a  proteid  which  is  similar  to  that  of  breast-milk  and  therefore 
ready  for  assimilation.  Eotch,  Holt,  and  others  still  maintain  that 
the  difficulty  is  in  the  way  of  complete  assimilation  of  the  casein  of 
cows'  milk,  while,  on  the  other  hand,  Jacobi,  Escherich,  Czerny  hold 
other  elements  of  the  milk  responsible  for  the  difficult  assimilation  of 
cows'  milk.     Czerny  goes  so  far  as  to  challenge  any  evidence  as  to 


MARASMUS  OB  INFANTILE  ATEOPHT.  261 

the  fact  that  casein  of  cows'  milk  is  difficult  of  digestion  even  by  the 
youngest  infant. 

The  Fats. — Jacobi  was  among  the  first  to  point  out  that  the  fats 
of  cows'  milk  were  the  main  difficulty  in  the  complete  assimilation  of 
cows'  milk  and  still  maintains  that  malnutrition  is  brought  about  in 
some  infants  by  too  great  fat  percentages.  Czerny  has  for  years 
gradually  worked  out  methods  of  feeding  which  are  based  on  the  con- 
viction that  the  fats  in  the  cows'  milk  are  exceedingly  noxious  to  some 
infants.  Czerny  and  Keller  have  shown  that  the  fats  cause  excessive 
production  of  acids  in  the  intestine,  an  acidosis.  In  these  disturbed 
conditions  of  nutrition,  resulting  in  atrophy,  ammonia  in  large 
amounts  is  excreted  in  the  urine  instead  of  urea.  The  formation  of 
ammonia  entails  a  drain  on  the  economy,  hence  the  emaciation. 
Excess  of  fats  in  the  food  favors  the  production  and  over-production 
of  acids  in  the  gut.  There  is  no  question  of  infection  for  the  condi- 
tions above  are  produced  in  the  face  of  utmost  cleanliness  and  a  germ- 
free  or  practically  bacterial-free  food. 

Cereals  and  Carbohydrates. — As  to  the  injury  done  to  infants  by 
cereals  and  carbohydrates  as  an  exclusive  diet,  there  can  be  but  one 
opinion.  The  newborn  infants,  though  they  bear  cereals,  as  barley, 
well  when  combined  in  dilute  solutions  witTi  milk,  do  not  bear  them 
well,  exclusively.  This  is  seen  in  many  cases  of  marasmus  in  which 
the  infants  from  the  start  were  fed  on  some  infant  food  which  in  the 
main  was  a  refined  cereal  or  a  cereal  combined  with  some  form  of 
sugar.  Such  foods  seem  to  agree  with  the  infants  at  first,  but  after 
a  while  they  develop  symptoms  which  become  cumulative  and  result 
in  injury  to  the  infant  nutrition.  Condensed  milk,  made  up  largely 
of  carbohydrate  or  that  with  a  low  proteid,  tends  to  bring  about 
the  symptoms  which  show  a  severe  disturbance  of  nutrition. 

Morbid  Anatomy. — It  must  be  kept  in  mind  that  whatever  is  found 
post  mortem  in  the  form  of  an  infection  is  an  after-effect  of  the 
reduced  physical  condition  of  the  infant  and  is  secondary  to  the  main 
condition  which  is  one  of  progressive  failure  of  nutrition. 

The  body  is  much  emaciated;  the  skin  hangs  in  folds  on  the 
extremities,  and  presents  hemorrhages  or  petechise.  The  lungs  may 
show  atelectatic  areas  or  may  be  the  seat  of  bronchopneumonia.  The 
heart  is  small  and  the  muscle-fibre  pale.  In  many  cases  the  stomach 
is  dilated  and  the  mucous  membrane  pale.  The  small  intestine  shows 
few  changes.  The  Peyer's  patches  may  be  slightly  raised  and  show 
the  so-called  shaven-beard  appearance.  The  follicles  of  the  colon 
may  be  slightly  prominent.  The  microscopical  changes  in  the  gut 
are  not  characteristic.  In  some  places  the  follicles  are  the  seat  of 
catarrhal  inflammation.  Both  in  the  stomach  and  the  intestines  there 
are  patches  where  there  is  an  absence  of  glandular  tissue;  in  its  place 


262 


DISEASES  DVE  TO  DISTUBBANCES  OF  NUTRITION. 


Fig.  34. 


is  a  newlj  formed  connective  tissue  composed  of  round  and  spindle- 
shaped  cells.  The  villi  of  the  gut  have  disappeared.  The  whole 
mucosa  is  thinner  than  is  normal  (Baginsky).  On  the  other  hand, 
these  changes  may  not  be  marked. 

Heuhner  thinks  that  these  changes  in  the  gut  described  by  Ba- 
ginsky are  postmortem  artifacts  and  are  not  the  result  of  the  disease. 
The  liver  is  fatty  and  may  be  enlarged.  The  spleen  is  small.  The 
kidneys  may  be  pale,  especially  in  the  cortex,  and  may  be  the  seat 
of  parenchymatous  degeneration.  The  lymph-nodes  of  the  mesentery 
may  be  enlarged. 

Symptoms. — The  symptoms  of  infantile  atrophy  are  rather  cumu- 
lative and  begin  to  show  themselves  after  a  time  of  feeding  which 
may  not  have  been  so  discouraging  at  first.     The  infant  may.  have, 
been  premature  or  of  fine  normal  development  at  birth.     Whether 

on  the  breast  or  bottle  the  signs 
of  disturbance  are  much  the 
same.  They  begin  with  slight 
marks  of  trouble.  The  color 
of  the  infant  fails  at  first ; 
there  are  slight  dyspeptic  dis- 
turbances, such  as  sjDitting  up, 
or  colic  and  restlessness ;  and 
then  the  first  serious  sign  that 
inroads  are  being  made  on  the 
economy  is  met  with  in  the 
stationary  weight.  With  the 
occurrence  of  this  stationary 
weight,  the  stools  are  either 
constipated,  dry  and  soapy  in 
consistency,  or  they  may  be 
soft  and  curdy.  The  infants 
cry  incessantly  and  have  a 
ravenous  appetite  which  is  not 
appeased  by  more  food.  The 
greater  amount  of  food  which 
is  given  under  the  mistaken  idea  that  they  are  hungry  does  not 
nourish  the  infants  and  added  to  the  serious  symptom  of  stationary 
weight  we  finally  have  loss  of  weight. 

The  condition  is  now  progressive.  The  muscles  and  tissues  lose 
their  physiological  tone,  the  fat  disappears  and  the  skin  hangs  loose 
on  the  extremities,  the  face  is  thin  and  the  infant  has  an  old,  senile 
appearance,  the  chest  is  emaciated,  the  ribs  show,  and  the  fonta- 
nelles  are  depressed.  Over  the  buccinator  muscle  is  a  small  cushion 
of  fat.  the  so-called  "  sucking  pads,"  which  persist  when  all  other 


Vertical  section  of  the  head  of  a  child 
two  months  of  age,  showing  the  sucking  pads 
(S.  C).     Symington. 


MARASMUS  OR  INFANTILE  ATROPHY.  263 

facial  fat  has  disappeared.  This  gives  the  cheeks  a  peculiarly  puffed 
look.  At  this  stage  infections  are  apt  to  add  to  the  seriousness  of 
the  situation.  Furuncles,  intertrigo  of  the  buttocks,  erosions  of  all 
kinds,  or  sprue,  are  apt  to  make  their  appearance  favored  by  the  least 
neglect.  The  buttocks  are  much  emaciated  and  the  tuber  ischii  show 
prominently.  The  heart  is  v^eak  and  in  the  last  stages  the  muscular 
sound  is  scarcely  audible.  The  patients  become  an  easy  prey  to 
gastro-intestinal  infection  with  resultant  diarrhoea  which  may  close 
the  scene.  The  temperature  if  no  infection  be  present  may  be  normal 
or  subnormal.  The  infants  in  many  cases  finally  lose  all  desire  for 
food.  Others  drink  with  avidity,  but  do  not  assimilate  the  food 
taken.  If  untreated,  these  infants  emaciate  until  they  are  reduced 
to  skin  and  bones.  They  grow  exceedingly  weak,  and  die  with  some 
intercurrent  infection,  such  as  pneumonia,  tuberculosis,  or  infectious 
disease. 

Treatment. — In  the  treatment  of  infantile  atrophy  lie  all  the 
problems  which  have  confronted  the  physician  in  infant  feeding.  If 
the  student  or  practitioner  desires  to  attain  great  success  he  must 
approach  each  individual  case  and  study  what  element  in  the  feed- 
ing is  at  fault.  As  a  rule  he  well  find  that  the  infant  has  been  fed 
haphazard  or  with  frequent  changes  of  formulae  without  any  par- 
ticular direction,  or  that  there  has  been  a  too  continued  effort  to  make 
the  infant's  digestion  conform  to  a  food  in  the  face  of  bad  results ; 
or  that  the  infant  has  been  fed  on  some  infant  food.  If  the  infant 
has  been  fed  on  cows'  milk,  either  the  quantity  has  been  too  great  in 
the  aggregate  or  the  quality  too  strong  as  it  is  called.  If  the  infant 
has  been  receiving  too  concentrated  a  mixture,  the  first  step  is  dilu- 
tion. In  mild  cases  this  alone  will  work  quite  well.  Too  great  a 
dilution  is  not  effective,  however,  because  if  the  fat  is  at  fault  and 
the  milk  is  diluted  too  much,  the  proteids  are  reduced.  Even  if  we 
finally  find  a  mixture  which  affords  certain  relief  to  the  symptoms, 
the  infant  does  not  increase  in  weight  because  something  is  lacking. 
In  such  cases  the  addition  of  cereal  will  solve  the  difficulty  and  an 
increase  of  weight  will  result.  Quite  often  this  is  ineffective  so  that 
in  addition  to  the  cereal  some  carbohydrate,  such  as  the  malted  foods, 
must  be  added.  In  such  cases  Keller  has  devised  a  modification  of 
the  old  Liebig  formula  by  which  the  cereal  and  malted  sugar  are 
added  to  the  milk.     He  has  called  this  malt  soup. 

In  other  cases  we  find  that  where  fats  are  not  borne  well  the 
butter  milk  described  elsewhere  has  given  excellent  results  because  it 
is  a  fat-free  food  rich  in  proteids  containing  also  a  cereal  and  carbo- 
hydrate (cane-sugar).  As  it  is  still  difficult  to  obtain  a  reliable 
butter  milk  and  an  account  of  the  great  danger  attending  the  use  of 
some  of  its  forms,  this  method  of  feeding  atrophic  infants  has  been 
abandoned  for  the  present. 


264  DISEASES  DUE  TO  DISTUBBANCES  OF  NUTRITION. 

It  will  tlius  be  seen  that  the  management  of  these  cases  presup- 
poses study  of  the  needs  of  each  particular  individual.  If  the  first 
few  attempts  to  feed  such  infants  do  not  result  in  palpable  progress 
there  should  be  no  dangerous  delay  and  experimentation,  but  the 
infants  should  be  given  the  human  breast  as  soon  as  possible.  No 
infant  is  too  old  to  place  at  the  breast.  With  patience  and  care  most 
infants,  even  if  past  the  first  period  of  infancy,  may  be  taught  to 
take  the  breast.  The  result  at  first  is  sometimes  discouraging,  as 
the  increase  in  weight  is  not  always  commensurate  with  the  expecta- 
tion, but  when  it  once  begins  it  is  nothing  short  of  marvellous  how 
an  infant  reduced  to  skin  and  bones  will  in  a  short  time  fully  double 
its  weight. 

With  the  feeding,  the  general  hygiene  of  the  infant  should  receive 
attention.  Daily  baths  with  sea-salt  and  open-air  life  are  especially 
indicated. 

In  infantile  atrophy  the  medical  and  mechanical  treatment  are  of 
less  importance  than  the  selection  of  proper  food.  For  this  reason 
we  should  not  seek  to  multiply  remedies.  The  movements  of  the 
bowels  in  some  cases  have  an  exceedingly  fetid  odor.  The  treatment 
is  begnin  with  the  administration  of  brisk  cathartics,  such  as  castor 
oil.  The  bowel  is  then  washed  out  once  a  day  until  the  character  of 
the  movements  has  improved.  If  there  is  a  tendency  to  diarrhoea, 
tannigen,  with  or  without  bismuth,  may  be  given  three  or  four  times 
daily.  If  there  is  any  great  amount  of  gas  generated  in  the  stomach, 
a  very  small  dose  of  dilute  hydrochloric  acid  and  pepsin  should  be 
given  daily  after  a  feeding. 


SECTION  V. 

THE  SPECIFIC  INFECTIOUS  DISEASES. 

THE    EXANTHEMATA. 

The  exanthemata,  scarlet  fever,  measles,  Eotheln,  varicella,  and 
variola,  are  acute  specific  infectious  diseases,  characterized  by  an 
eruption  on  the  skin,  the  so-called  exanthema  or  rash.  They  form  a 
distinct  group.  The  poison  or  infectious  element  originates  in  the 
body  of  the  patient.  The  nature  of  this  poison  is  unknown.  Though 
suspected  to  be  bacterial,  the  essential  cause  in  any  of  the  exanthemata 
has  not  been  isolated.  We  do  know,  however,  that  the  acute  exan- 
themata are  conveyed  from  one  person  to  another  by  direct  contact  or 
through  the  medium  of  the  atmosphere.  In  this  respect  they  differ 
essentially  from  such  diseases  as  typhoid  fever,  or  even  syphilis,  in 
which  the  morbific  agent  must  be  introduced  into  the  body.  They 
are  therefore  not  only  communicable  but  contagious  in  the  true  sense 
of  the  term.  Most  people  are  susceptible  to  some  of  the  exanthemata, 
such  as  measles  and  smallpox.  On  the  other  hand,  not  every  one 
exposed  to  contagion  will  contract  scarlet  fever  or  varicella.  Few 
persons  are  attacked  twice  by  the  same  exanthematic  affection,  but 
there  are  exceptions  to  this  rule.  An  attack  of  one  disease,  such  as 
measles,  does  not  confer  immunity  from  an  attack  of  another,  such  as 
scarlet  fever. 

The  exanthemata  occur  either  endemically  or  epidemically.  Each 
has  a  well-defined  period  of  incubation — that  is  to  say,  an  interval 
between  the  time  of  the  exposure  to  contagion  and  the  onset  of  char- 
acteristic symptoms.  In  the  different  exanthemata  this  interval 
varies  within  wide  limits.  The  period  of  incubation  seems  to  be 
more  accurately  determined  in  measles  than  in  the  other  exanthemata. 
It  is  well  established  that  two  of  the  exanthemata  may  occur  at  the 
same  time  in  the  same  subject.  This  is  not  a  point  in  favor  of  the 
identity  of  the  essential  cause  of  the  exanthemata.  On  the  contrary, 
it  is  an  accepted  fact  that  each  of  the  exanthemata  is  distinct  in  itself, 
and  that  each  disease  has  its  specific  essential  cause. 

SCARLET    FEVER. 

Scarlet  fever  is  an  acute  infectious  disease  with  a  characteristic 
rash  or  exanthema.     It  is  highly  contagious. 

Etiology. — It  has  not  as  yet  been  established  whether  the  infec- 

265 


266  THE  SPECIFIC  INFECTIOUS  DISEASES. 

tious  agent  is  a  micro-organism,  although  streptococci  have  been 
isolated  from  the  secretions  and  scales  in  the  desquamative  period, 
l^either  do  we  know  whether  there  is  an  organism,  a  protozoan,  in 
the  circulating  blood.  Mallorj,  Duval  and  Field  have  described  cer- 
tain protozoa-like  bodies  in  the  lymph-spaces  of  the  skin.  Field 
regards  them  as  being  derived  from  the  protoplasm  of  degenerated 
epithelial  cells. 

The  atmosphere  about  the  patient  seems  in  most  cases  to  be  the 
zone  of  contagion.  The  nearer  a  person  has  been  to  the  patient  the 
more  likely  is  he  to  convey  the  disease  to  a  third  person.  Articles  of 
clothing  may  retain  the  infection  for  months.  Scales  from  the  skin 
of  the  patient,  dried  secretions,  the  urine  if  nephritis  exists,  and  faeces 
are  also  mediums  of  infection.  The  longer  the  physician  remains 
near  the  patient  the  more  likely  is  he  to  convey  the  disease.  This 
mode  of  infection  occurs.  Osier  records  his  belief  in  having  carried 
infection  to  a  patient.  Foodstuffs  handled  by  those  suffering  from 
the  disease  or  by  those  who  have  been  near  patients  may  convey  the 
disease.  This  is  especially  the  case  with  milk,  which  is  said  to  have 
been  the  cause  of  epidemics  in  England.  The  poison  of  scarlet  fever 
seems  to  pervade  the  ward  or  sick-room  for  a  long  time.  Whether 
this  period  extends  over  two  years,  as  recorded  by  Murchison,  is  a 
matter  not  yet  settled.  We  do  not  yet  know  how  the  poison  obtains 
entrance  to  the  body.  The  discharge  from  a  scarlatinal  otitis  is  said 
to  be  capable  of  communicating  the  disease. 

Susceptibility. — All  children  exposed  to  infection  do  not  contract 
the  disease.  It  is  less  contagious  than  measles.'  On  the  other  hand, 
although  a  person  may  be  expoi>ed  once  and  escape,  he  is  not  neces- 
sarily immune  to  future  exposures.  A  nurse  attended  many  cases 
for  me  before  contracting  the  disease.  As  a  rule,  one  attack  of  scarlet 
fever  protects  a  person  from  subsequent  attacks.  The  literature 
records  cases  of  well-observed  second  and  third  attacks.  The  author 
has  seen  cases  of  a  second  attack.  We  should,  however,  be  cautious 
in  accepting  reports  of  repeated  attacks.  Rotheln  may  have  been 
mistaken  for  scarlet  fever. 

Occurrence. — Scarlet  fever  occurs  at  any  age,  and  in  all  countries, 
being  endemic  in  K'orth  America  and  Europe.  It  is  most  prevalent 
in  autumn  and  winter  (September  to  February) .  It  remains  endemic 
wherever  introduced.  Sporadic  cases  occur.  It  may  occur  sporad- 
ically for  years  and  not  become  epidemic.  Epidemics  of  scarlet 
fever  are  less  frequent  than  those  of  measles.  It  occurs  also  in  epi- 
demics. In  epidemics  only  38  per  cent,  of  the  population  are 
affected.  There  is  therefore  an  immunity  of  the  majority  (Jiir- 
gensen,  on  the  Faroe  Epidemics).  As  a  rule,  fully  56  per  cent,  of 
those  exposed  before  the  twentieth  year  contract  the  disease. 


SCAELET  FEVEE.  267 

Incubation. — According  to  the  German  authorities,  scarlet  fever 
has  an  incubation  period  of  from  eight  to  eleven  days.  English 
authors  (Murchison)  fix  the  period  at  from  three  to  six  days.  The 
vast  majority  of  cases  develop  v^^ithin  a  period  of  from  three  to  five 
days  after  exposure.  If  eleven  days  elapse  v^ithout  the  appearance 
of  symptoms,  we  may  with  reasonable  certainty  say  that  the  danger 
of  infection  is  passed.  Cases  of  thirty  days'  incubation  are  recorded, 
and  the  author  had  a  case  in  his  practice  in  which  a  physician  con- 
veyed the  disease,  the  boy  being  attacked  three  weeks  after  his  visit. 
In  all  such  prolonged  periods  of  incubation,  however,  there  is  a  proba- 
bility of  a  more  recent  exposure.  The  contagion  is  active  during  the 
period  of  incubation  and  during  the  eruptive  and  desquamative  stages. 
The  consensus  of  opinion  is  that  the  contagion  diminishes  in  the 
desquamative  stage.  In  America  desquamation  is  considered  a  bar 
to  the  mingling  of  convalescents  with  those  who  are  well.  In  England 
patients  are  discharged  from  the  hospitals  before  the  desquamation 
is  over.  We  should  exercise  great  caution  in  allowing  convalescents 
to  mingle  with  the  healthy,  especially  if  there  is  a  residual  otitis  or 
adenitis  or  any  purulent  focus,  for  such  pus  is  considered  capable  of 
conveying  the  disease.  Strange  to  say,  there  are  no  positive  data  on 
this  point.     Contagion  will  be  treated  more  fully  under  Prophylaxis. 

Immunity.- — Although  there  is  no  absolute  immunity  at  any  age, 
scarlet  fever  attacks  nursing  infants  lees  frequently  than  older  chil- 
dren. We  have  no  positive  data  as  to  transmission  of  the  affection 
in  utero.  Cases  are  recorded  in  which  the  newly  born  infant  has 
been  attacked,  but  some  authors  are  inclined  to  look  on  such  cases  with 
doubt.  In  certain  sets  of  cases  the  affection  takes  on  a  virulent  form, 
in  which  all  the  members  of  a  family  attacked  will  have  complica- 
tions, septic  or  otherwise,  of  a  fatal  character.  All  had  septic  malig- 
nant fever.  There  may  in  such  cases  be  an  element  of  mixed  infec- 
tion (Henoch). 

Symptomatology. — Scarlet  fever  does  not  present  uniform  symp- 
toms. A  general  description  of  the  disease  can  hardly  be  given 
without  misleading  the  student.  During  an  epidemic  or  during  the 
prevalence  of  scarlet  fever,  there  are  a  number  of  cases  of  angina  in 
which  no  exanthema  of  scarlet  fever  is  seen.  This  is  especially  so 
with  those  whose  duties  keep  them  near  scarlet  fever  patients.  There 
is  no  doubt  that  such  anginal  cases  are  capable  of  conveying  the  dis- 
ease to  others.  A  case  of  this  kind  has  come  under  the  author's 
notice.  A  nurse  suffering  from  an  angina  went  from  a  scarlet  fever 
case  to  a  healthy  child.  Although  the  nurse  had  taken  all  external 
precautions  she  conveyed  the  disease  to  the  child.  This  raises  the 
question  of  scarlet  fever  sine  exanthema.  Let  us  say  that  scarlet 
fever  poison  can  cause  a  specific  angina  capable  of  conveying  the  dis- 


268 


TEE  SPECIFIC  INFECTIOUS  DISEASES. 


ease  to  the  healthy.     Certain  forms  of  exanthema  of  scarlet  fever  are 
very  evanescent,  and  in  anginal  cases  may  escape  observation. 

Period  of  Incubation. — The  period  of  incubation  has  no  fixed 
symptomatology.  In  many  cases  the  symptoms  begin  with  the  ap- 
pearance of  the  eruption.  The  children  play  about;  they  have  a 
slight  angina,  but  do  not  complain.  This  is  apt  to  be  the  case  with 
children  who  are  sufferers  from  chronic  catarrh,  enlarged  tonsils,  or 
adenoids.  In  other  cases  the  invasion  of  the  disease  is  a  stormy  one. 
There  may  be  an  initial  convulsion  j)receded  by  a  sharp  rise  in  tem- 
perature. Examination  in  such  cases  may  show,  previous  to  the 
appearance  of  the  eruption,  a  marked  angina  or  a  membranous  deposit 
on  the  tonsils,  but  nothing  more.  Other  children  suffer  from  a  ton- 
silitis  of  moderate  severity,  a  marked  febrile  movement,  and,  what  is 
characteristic,  attacks  of  anorexia  and  vomiting.     A  chill,  followed 


Fig 

35 

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Moderately  severe  scarlet  fever  ;  female  child  four  years  of  age. 
Observed  from  the  outset. 


Normal  course. 


by  fever  and  vomiting,  ushers  in  a  large  number  of  scarlatinal  anginas. 
Occasionally  the  symptoms  of  invasions  are  so  mild  and  evanescent 
as  to  escape  the  notice  of  even  watchful  parents.  These  are  the  eases 
in  which  the  first  symptom  to  attract  attention  belongs  to  a  later 
period  of  the  disease  or  to  some  of  the  complications.  There  are  thus 
all  degTees  in  the  severity  of  the  symptoms  of  the  period  of  invasion, 
varying  with  the  susceptibility  of  the  subject  and  the  virulence  of  the 
epidemic. 

General  Course  of  the  Disease. — An  attack  of  scarlet  fever  takes  a 
certain  general  course.  After  the  initial  symptoms  of  vomiting  and 
abrupt  onset  of  fever  twelve  to  thirty-six  hours  elapse,  when  an  erup- 
tion or  rash  appears  on  the  skin;  this  eruption,  though  characteristic, 
varies  greatly  in  intensity,  mode  of  spreading,  and  distribution.     The 


SCARLET  FEVER. 


269 


fever  is  now  very  High;  the  eruption  spreads  and  becomes  more 
intense  and  general  (Fig.  35).  At  the  greatest  intensity  of  the  erup- 
tion or  florescence  the  fever  is  highest.  In  typical  cases  of  scarlet 
fever  the  eruption  reaches  its  full  development  and  runs  its  course 
within  two  to  six  days.  At  the  end  of  this  time  it  fades,  and  desqua- 
mation begins.  The  fever  subsides  gTadually,  leaving  the  patient 
convalescent.  The  period  of  invasion  is  not  so  sharply  defined  as  in 
measles,  nor  is  the  stage  of  eruption  so  distinct  and  uniform  as  in  that 
disease.  The  length  of  the  period  of  desquamation  in  both  measles 
and.  scarlet  fever  varies. 

The  malignant  cases  may  at  first  appear  mild.     The  children  are 
taken  with  vomiting  and  a  moderately  high  fever,  and  the  eruption 


Fig. 

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Malignant  scarlet  fever ;  ursemic  symptoms  from  outset.  Boy,  six  years.  Sopor 
increasing  to  coma  ;  bloody  urine.  Involuntary  passage  of  urine  and  faeces.  Death  in 
three  days  after  onset  of  symptoms. 


appears.  While  the  eruption  is  spreading,  however,  the  patients 
become  stupid,  and  within  a  few  hours  after  the  appearance  of  the 
exanthema  pass  into  a  state  of  coma.  The  urine  is  diminished  in 
quantity  or  supj)ressed,  and  contains  blood,  albumin,  and  casts.  The 
temperature  remains  elevated  (Fig.  36).  The  pulse  is  rapid  and  at 
times  thready.  These  patients  remain  comatose  and  die  within  a  few 
days  (three  or  four)  of  the  onset  of  the  symptoms.  In  other  malig- 
nant cases  the  affection  of  the  throat  and  adjacent  lymph-nodes  is  a 
leading  factor  in  the  septic  phenomena,  while  the  kidneys  show  very 
little  participation  in  the  general  toxaemia.  Such  patients  will  show 
necrotic  pseudomembranous  inflammation  in  the  fauces  after  the 
eruption  is  fully  developed.  The  glands  of  the  neck  are  involved. 
The  temperature  ranges  from  103°  to  105°  F.  (39.4°  to  40.5°  C), 
with  daily  remissions.  The  patients  have  a  sallow,  septic  appearance, 
and  are  stupid  and  irritable.     The  exanthema  fades  slightly  after 


270  IRE  SPECIFIC  INFECTIOUS  DISEASES. 

having  been  in  efflorescence.  Tlie  Ijmph-nodes  in  the  neck  enlarge 
to  great  size.  These  patients  maj  die  in  the  second  week  from  gen- 
eral toxaemia.  Between  the  normal  course  and  these  malignant  forms 
there  are  all  degrees  of  severity  and  mildness  in  this  affection. 

Surgical  Scarlet  or  Infection  of  Wounds  with  Scarlet  Fever. — ■ 
Maunder  and  Murchison  called  attention  to  the  fact  that  patients 
with  wounds  are  prone  to  contract  scarlet  fever  more  readily  than 
others.  Hermann  has  recently  reported  several  cases.  It  is  of  in- 
terest that  burns  are  apt  to  be  followed  by  an  outbreak  of  scarlet  fever. 
Leiner  has  described  such  cases  and  I  have  seen  a  number  and  observed 
very  active  and  extensive  desquamation  follow  the  fading  of  the  erup- 
tion as  well  as  complicating  nephritis. 

The  Angina. — The  angina  of  scarlet  fever  is  limited  to  the  pillars 
of  the  fauces,  the  uvula,  the  tonsils,  and  retropharynx.  The  angina 
may  be  simply  a  slight  redness  of  the  fauces  and  very  slight  swelling 
of  both  tonsils.  The  lymph-nodes  at  the  angle  of  the  jaw  may  be 
very  slightly  enlarged.  The  tonsils  may  be  so  greatly  enlarged  as 
to  close  the  opening  of  the  fauces.  This  is  likely  to  be  the  case  if 
there  has  been  antecedent  hypertrophy  of  the  tonsils.  ISTo  mem- 
branous deposit  may  be  seen,  yet  there  may  be  a  distinct  lacunar 
form  of  tonsillitis.  The  lymph-nodes  at  the  angle  of  the  jaw  may 
be  much  larger  than  in  the  milder  anginal  cases.  The  swelling  of 
the  lymph-nodes  may  involve  the  connective  tissue  about  them  in  a 
phlegmonous  mass.  This  is  especially  so  in  the  severe  septic  forms 
of  scarlatinal  angina  of  the  streptococcus  variety. 

Membranous  Angina. — Membrane  spreading  to  the  pillars  of  the 
fauces  may  be  present  on  one  or  both  tonsils.  This  condition  was 
formerly  called  scarlatinal  diphtheria.  In  the  vast  number  of  cases 
of  scarlet  fever — in  fact,  in  all  the  uncomplicated  cases — this  mem- 
brane is  not  a  true  diphtheria  like  the  diphtheria  of  Loffler.  It  is  a 
streptococcus  membrane  (diphtheroid),  caused  by  the  streptococcus 
of  pseudomembranous  formations.  This  membrane  may  involve  the 
posterior  pharynx  and  nares,  and  spread  downward  into  the  larynx 
and  trachea.  True  diphtheria  of  Loffler  occurs  in  those  cases  of 
scarlet  fever  which  have  been  exposed  to  the  infection  of  diphtheria 
at  or  about  the  time  of  the  outbreak  of  the  scarlet  fever  or  at  some 
period  during  the  course  of  the  disease.  The  membrane  in  these  cases 
will  show,  on  examination,  the  Bacillus  diphtherise  of  Loffler.  These 
cases  of  true  di])htheria  complicating  scarlet  fever  are  exceptional. 

The  pseudodiphthoria  is  usually  caused  by  a  streptococcus  of  the 
scarlatinous  variety.  In  some  forms  of  scarlet  fever  this  pseudo- 
membranous inflammation  of  the  tonsils  becomes  a  primary  factor  in 
the  disease  at  an  early  period  before  the  full  development  of  the  erup- 
tion.    This  process  involves  the  lymph-nodes  and  the  whole  connective 


8CABLET  FEVEB.  27 1 

tissue  of  the  neck  below  the  jaw  in  a  necrotic  streptococcus  inflamma- 
tion. In  many  cases  a  true  streptococcsemia  may  result  from  the 
entrance  of  the  streptococci  into  the  circulation.  In  other  cases  the 
patient  may  have  passed  through  a  mild  eruptive  stage  and  on  the 
tenth  to  the  fourteenth  day  a  severe  pseudomembranous  tonsillitis 
makes  its  appearance  with  marked  glandular  enlargements  and  high 
fever.  Some  of  these  cases  are  also  complicated  with  a  severe 
nephritis.  Retropharyngeal  abscess,  mediastinal  burrowing  abscess, 
abscess  pointing  on  the  external  portion  of  the  neck,  or  empyema,  may 
result  from  the  necrotic  tonsillar  affection  by  extension  through  the 
lymph-nodes.  Secondarily,  a  general  systemic  infection  may  result 
in  such  cases. 

The  mucous  membrane  of  the  mouth  presents  nothing  character- 
istic in  the  great  majority  of  cases  of  scarlet  fever.  The  buccal 
mucous  membrane  is  pale,  and  of  a  normal  hue  at  first;  the  soft 
palate  may  present  a  few  red,  irregularly  shaped  spots  or  red  streaked 
areas,  or  these  may  be  absent.  Later  in  the  course  of  the  disease  a 
stomatitis  may  appear.  This  is  more  likely  to  occur  in  the  so-called 
septic  case.  In  these  the  superficial  epithelium  is  removed;  the 
mucous  membrane  has  a  dry,  red,  beefy  appearance.  The  lips  are 
fissured  and  bleed  easily. 

The  tongue  in  most  cases  of  scarlet  fever  is  furred  at  the  outset, 
and  may  present  a  slightly  reddened  appearance  at  the  borders  and 
tip.  In  some  cases  there  is  the  so-called  characteristic  strawberry 
tongue.  This  appearance  is  caused  by  an  undue  prominence  and 
erection  of  the  papillge  of  the  tongue,  especially  at  the  tip.  The  tip 
is  red,  and  with  the  prominent  papillse  gives  the  appearance  of  a 
strawberry  or  of  the  tongue  of  the  lower  animals  (cat).  In  many 
cases  the  tongue  later  becomes  denuded  of  epithelium  and  shows  the 
erected  papillse  on  the  dorsum ;  in  others  it  becomes  dry  and  fissured. 
The  latter  condition  is  seen  in  the  toxic  cases. 

The  Exanthema. — The  exanthema  of  scarlet  fever,  though  very 
characteristic  in  appearance,  varies  more  than  in  any  of  the  other 
exanthemata  in  mode  of  appearance,  distribution,  spreading,  and  in 
duration.  In  the  mild  cases  the  eruption  is  sometimes  so  evanescent 
as  to  escape  notice.  In  other  cases  it  appears  only  on  certain  parts 
of  the  surface.  It  may  be  very  discrete  in  form  and  punctate. 
Usually  it  first  appears  on  the  upper  part  of  the  chest  about  the  clavi- 
cles, spreads  down  the  chest,  and  around  upon  the  back.  At  this 
time  it  is  also  seen  on  the  neck,  beneath  the  jaw,  behind  the  ears,  and 
on  the  temples. 

It  consists  of  a  minute,  delicately  punctate  rose-colored  rash. 
The  punctate  appearance  is  the  distingaiishing  feature  of  the  erup- 
tion.    At  the  outset  this  punctate  character  is  best  observed  on  the 


272  TEE  SPECIFIC  INFECTIOUS  DISEASES. 

chest,  abdomen,  and  the  nates.  If  the  eruption  has  in  places  become 
confluent,  the  skin  shows  a  uniform  redness.  In  such  cases  the  punc- 
tate character  of  the  rash  can  best  be  discovered  by  studying  the  skin 
from  a  distance  in  bright  daylight.  It  will  then  be  made  out  dis- 
tinctly in  those  places  in  which  the  rash  is  most  recent.  A  favorite 
method  is  to  undress  the  patient  and  study  the  lower  abdomen,  the 
thighs,  and  nates.  In  the  early  cases  the  punctate  character  of  the 
rash  is  apparent  on  the  neck  and  behind  the  ears. 

The  appearance  of  the  face  at  the  outset  of  the  disease  is  charac- 
teristic. There  is  a  pallor  about  the  mouth  and  alse  nasi,  while  the 
cheeks  are  flushed  with  a  flame-like  erythema.  The  eyes  may  be 
injected.  The  cheeks  do  not  show  the  characteristic  punctate  rash, 
although  flushed  either  from  the  fever  or  intense  dermatitis,  which 
involves  the  whole  surface.  The  eruption  spreads  from  above  down- 
ward, involving  the  arms  and  forearms,  hands,  and  lower  extremities. 
It  retains  the  punctate  character  wherever  it  spreads,  but  loses  this 
characteristic  after  it  has  been  out  for  a  short  time  and  become  con- 
fluent. When  confluent  the  rash  causes  the  skin  to  appear  uniformly 
red  and  swollen.  In  some  places,  especially  the  extensor  surface 
of  the  hands  and  forearms,  the  eruption  is  blotchy  and  erythema- 
tous. The  skin  is  roughened  in  patches  by  the  erection  of  the  papillae. 
In  other  cases,  and  especially  in  those  occurring  in  summer,  the  skin 
is  studded  with  myriads  of  minute  vesicles,  or,  again,  the  skin  may 
present  minute  pustules.  There  is  pruritus  in  the  cases  in  which  the 
dermatitis  is  severe.  The  rash  of  scarlet  fever  attains  its  full  devel- 
opment at  the  end  of  two  or  three  days.  It  is  then  said  to  be  in 
efilorescence.  It  remains  out  a  variable  length  of  time,  in  some  cases 
six  days.  In  other  cases  the  eruption  may  develop  fully  in  two  days 
and  then  fade.  Cases  in  which  the  rash  is  visible  for  only  twenty- 
four  hours  are  not  uncommon. 

The  appearance  of  a  fading  scarlet  fever  rash  is  very  character- 
istic if  it  has  involved  the  whole  surface.  The  skin  is  dotted  here 
and  there  by  raised  papillae,  and  appears  as  if  irregularly  and  lightly 
daubed  with  rouge.  Even  a  fading  rash  may  be  easily  diagnosed  by 
an  experienced  observer.  In  mild  cases  the  rash  may  disappear 
within  twelve  hours,  leaving  no  vestige  of  its  presence.  In  other 
cases  the  rash  appears  only  on  the  lower  part  of  the  abdomen  and 
upper  part  of  the  thighs. 

The  eruption  on  the  lower  part  of  the  extensor  surface  of  the 
forearms,  and  also  on  that  of  the  legs,  is  apt  to  assume  a  blotchy, 
roseola-like  appearance.     Such  cases  have  been  mistaken  for  measles. 

Abscesses  or  furuncles,  multiple  or  single,  may  involve  the  skin. 
In  rare  cases  gangrenous  processes  have  been  recorded.  A  secondary 
infection  may  be  assumed  in  all  of  these  cases. 


SCARLET  FEVEB.  273 

The  Fever. — In  the  first  few  hours  there  is  a  rapid  rise  of  the 
temperature  to  104°  or  105.8°  F.  (40°  or41°  C).  It  remains  high  with 
morning  remissions  until  the  eruption  on  the  surface  reaches  its  full 
development.  With  the  fading  of  the  eruption  the  temperature  falls, 
and  within  six  days,  if  the  case  is  uncomplicated  and  typical,  becomes 
subnormal.  The  patient  may  show  a  subnormal  temperature  for  a 
few  days,  after  which  it  may  rise  to  the  normal.  In  some  cases  the 
temperature  may  rise  very  rapidly,  reaching  its  highest  point  within 
a  few  hours.  It  may  then  fall  to  the  normal  rapidly,  though  the 
eruption  be  still  present.  Wunderlich  and  Henoch  record  cases  of 
profuse  exanthema  with  a  mild  febrile  course  or  practically  afebrile 
curve,  101°  F.  (38.4°  C),  falling  rapidly  to  100.4°  F.  "(38°  C.) 
within  twenty-four  hours. 

In  those  cases  in  which  there  are  complication's  either  in  the 
throat,  ear,  joints  (rheumatism),  or  serous  cavities,  the  temperature- 
curve  will  be  influenced  accordingly  and  will  continue  for  days  at  a 
low  range,  102°  to  103°,  with  daily  remissions.  In  other  cases, 
evening  remissions  may  occur  instead  of  morning  ones.  After  the 
fading  of  the  eruption  the  fever  may  continue  for  days,  100.4°  to 
102.2°  F.  (38°  to  39°  C),  in  the  absence  of  any  complication. 
After  days  or  weeks  of  absence  of  temperature  there  may  occur  a 
distinct  rise  and  a  species  of  relapse  similar  to  that  seen  in  typhoid 
fever.  This  is  probably  due  to  a  form  of  secondary  streptococcus 
infection.  During  the  height  of  the  eruption  the  temperature  may 
reach  107°  F.  (41.6°  C),  although  in  mild  cases  it  may  not  be  over 
103°  F.  (39.4°  C).  In  cases  of  septic  infection,  especially  of  the 
lymph-nodes,  or  in  streptococcus  diphtheria,  with  infection  of  the 
lymph-nodes,  the  temperature-curve  will  be  of  a  remittent  character, 
falling  and  rising  once  or  twice  in  twenty-four  hours,  and  may  retain 
this  character  throughout  the  affection.  Uraemia  or  any  affection  of 
the  pleura,  lungs,  or  heart  will  be  ushered  in  by  a  rise  of  temperature 
even  if  it  has  returned  to  the  normal.  If  a  complication  occurs  early 
in  the  disease,  the  temperature  will  fail  to  drop  to  normal  with  the 
fading  of  the  eruption  (Fig.  34).  Incases  of  otitis  persisting  through 
the  stage  of  desquamation  there  will  sometimes  be  an  evening  rise, 
although  the  ears  are  discharging  freely.  In  such  cases  the  bone  may 
be  involved  (mastoid  disease).  In  severe,  malignant  forms  in  which 
symptoms  of  profound  sepsis,  such  as  coma  or  stupor,  are  present 
from  the  outset,  the  temperature  remains  persistently  high  (105.6° 
F.,  40.8°  C),  remitting  a  degree  toward  morning.  The  temperature 
remains  high  until  the  fatal  issue  (see  Fig.  36). 

Desquamation.- — The  period  of  desquamation  begins  as  soon  as 
the  exanthema  commences  to  fade.  Generally  speaking,  since  the 
exanthema  first  appears  on  the  upper  part  of  the  chest  and  neck  we 

18 


274 


THE  SPECIFIC  INFECTIOUS  DISEASES. 


should  expect  desquamation  to  begin  there.  It  may  be  in  fine,  branny 
scales,  such  as  are  seen  in  measles ;  or  else,  as  is  most  common,  the 
skin  peels  in  larger  particles.  The  hands  and  feet  show  the  largest 
scales,  and  complete  casts  of  the  hands  and  feet  are  sometimes  shed. 
I  have  seen  the  nails  shed  completely  twelve  weeks  after  the  attack. 
The  desquamation  may  be  scarcely  perceptible.  In  some  cases  only 
certain  parts  of  the  extremities,  such  as  the  toes  or  inner  portion  of 
the  thighs,  show  desquamation.  It  is,  however,  always  present. 
Desquamation  in  itself  is  not  a  pathognomonic  symptom  of  scarlet 
fever.  It  occurs  in  forms  of  dermatitis  which  bear  no  relationship 
to  the  disease.  It  is  still  a  subject  of  debate  whether  cases  of  angina 
without  an  exanthema  may  desquamate.     Henoch  is  inclined  to  think 

Fig.  37. 


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Scarlet  fever,  moderate  severity,  in  a  boy  six  years  of  age.  Stiows  tlie  delay  in  the 
drop  of  the  temperature  due  to  complicating  otitis  of  the  right  ear  at  the  outset  of  the 
period  of  desquamation. 


this  possible.  We  should  remember  that  an  evanescent,  slightly 
marked  exanthema  may  escape  the  notice  of  even  the  most  careful 
observer. 

The  duration  of  desquamation  is  variable.  There  are  cases  in 
which  a  secondary  desquamation  occurs  after  the  primary  one  has  run 
its  course.  The  severity  of  desquamation  has  no  relation  to  the 
intensity  of  the  exanthema.  Some  very  marked  cases  of  scarlatina 
desquamate  less  than  those  in  which  the  eruption  has  been  faintly 
marked.  The  average  duration  of  desquamation  is  six  weeks 
(Kellogg). 

The  Nose. — The  close  relationship  of  the  nasal  passages  to  the 
pharynx  facilitates  the  invasion  of  bacteria  from  the  throat.  The 
nasal  passages  become  affected  simultaneously  with  the  severe  angina. 
There  is  a  severe  catarrhal  or  pseudomembranous  inflammation  of 
the  mucous  membrane.  In  the  so-called  septic  cases  there  may  be 
an  ichorous  discharge  from  the  nostrils.  There  will  be  in  such  cases 
erosions,  and  sometimes  fetor,  with  the  discharge  of  necrotic  tissue 
through  the  nasal  passages.     Necrosis  of  the  cartilaginous  and  bony 


SCABLET  FEVEB. 


275 


structures  may  result.  In  other  forms  there  is  a  pseudomembranous 
deposit  around  the  opening  of  the  nostrils  extending  up  into  the  nasal 
passages.  Casts  of  the  nasal  passages  may  be  expelled.  The  mem- 
brane may  leave  a  bleeding  surface. 

Ear. — Duel  found  the  ears  affected  in  20  per  cent,  of  the  cases 
of  scarlet  fever.  Generally  both  ears  are  diseased.  Deafness  is 
frequently  a  result  of  otitis.  Ten  per  cent,  of  those  who  suffer  from 
deaf-mutism  can  trace  their  affliction  to  scarlet  fever.  Usually  the 
ears  become  affected  in  the  third  week,  although  they  may  be  involved 
at  the  outset  of  desquamation.  The  affection  of  the  ears  is  ushered 
in  by  a  rise  of  temperature  and  manifestations  of  pain  (Fig.  38). 
Occasionally  tinnitus    and   deafness   are  initial   symptoms.     There 


Fig.  38, 

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Female  child,  two  and  a  half  years  of  age.     A  mild  form  of  scarlet  fever  complicated  In 
the  second  week  by  an  otitis. 

may  be  convulsions  or  even  cerebral  symptoms.  The  onset  of  ear 
trouble  may  be  insidious,  and  not  suspected  until  the  purulent  dis- 
charge makes  its  appearance.  If  there  are  premonitory  symptoms, 
they  may  precede  the  perforation  by  one  to  three  days.  Ear  compli- 
cations in  scarlet  fever  are  always  of  serious  moment.  Meningitis, 
•sinus  thrombosis,  and  abscess  of  the  brain  are  among  the  more  serious 
results,  and  may  result  long  after  the  fever  has  run  its  course.  The 
onset  of  otitis  usually  occurs  during  the  period  of  desquamation. 
The  patient  may  be  up  and  about.  There  is  still  some  redness  of 
the  throat,  with  swelling  of  the  lymph-nodes.  There  is  a  sudden  rise 
of  temperature  to  103°  or  104°  F.  (39.4°  or  40°  C).  The  child 
begins  to  vomit  food  and  has  headache.  At  night  the  child  starts 
from  sleep  and  cries  as  if  in  pain.  Children  do  not  always  locate 
the  pain  in  the  ear.  The  reason  is  that  the  pain  occurs  before  the 
child  is  quite  awake.  The  sleep  is  restless.  The  muscles  of  the  face 
and  hands  twitch  in  sleep.  These  symptoms  may  at  times  abate. 
The  temperature  may  fall  to  the  normal  and  then  rise  sharply.  Any 
of  these  symptoms  should  direct  attention  to  the  ear. 


276  TRE  SPECIFIC  INFECTIOUS  DISEASES. 

The  mastoid  may  become  the  seat  of  inflammation  in  the  fifth  or 
sixth  week.  The  ears  may  have  been  discharging  very  freely.  The 
child  is  not,  however,  free  from  fever.  At  times  during'  the  day  the 
patient  complains  of  frontal  headache,  is  drowsy,  and  the  temperature 
shows  a  rise  to  102°  or  103°  F.  (38.5°  or  39.9°  C).  There  is  ten- 
derness behind  the  ear  or  in  front  of  the  auditory  meatus.  There 
may  be  a  slight  blush  above  and  behind  the  pinna.  In  these  cases 
the  mastoid  may  be  the  seat  of  suppuration.  There  are  forms  of 
otitis  which  occur  on  the  eighth  day  of  the  disease.  The  temperature 
does  not  fall  to  the  normal.  The  patient  has  begun  to  desquamate, 
but  the  temperature  remains  elevated  a  degree  or  more  and  takes 
fully  three  or  four  days  longer  to  fall  to  99°  F.  (3Y.2°  C.)  in  the 
rectum  than  in  an  uncomplicated  case.  At  the  eleventh  day  of  the 
disease  pain  is  complained  of.  The  drumhead  is  found  to  be  bulging. 
An  insidious  serous  otitis  media  is  in  progress. 

The  Eye. — Conjunctivitis  may  appear  in  some  cases  of  scarlet 
fever  as  a  result  of  a  mixed  infection.  The  lachrymal  duct  is  the 
canal  through  which  such  infection  travels.  Conjunctivitis  in  cases 
of  gangrenous  pharyngitis  and  rhinitis  may  lead  to  panophthalmitis 
and  destruction  of  the  eye. 

Lymph-nodes. — The  lymph-nodes  in  various  parts  of  the  body 
enlarge  in  scarlet  fever.  Those  situated  at  the  back  of  the  neck 
behind  the  posterior  border  of  the  sternomastoid  muscle  may  enlarge 
some  days  before  the  appearance  of  the  exanthema.  At  the  time  of  the 
appearance  of  the  eruption  we  may  find  that  the  lymph-nodes  in  the 
axilla,  inguinal  region,  and  those  at  the  angle  of  the  jaw,  are  enlarged. 
In  other  cases  the  lymph-nodes,  except  those  at  the  angle  of  the  jaw, 
may  not  be  perceptibly  enlarged.  In  some  cases  the  lymph-nodes  at 
the  angle  of  the  jaw  may  enlarge  at  the  end  of  the  second  week,  with 
a  distinct  rise  of  temperature  to  104°  F.  (40°  C.)  or  more,  as  a 
result  of  reinfection  through  the  tonsils  and  pharynx.  The  con- 
nective tissue  of  the  neck  beneath  the  body  of  the  jaw  is  involved  in 
the  inflammation  of  the  nodes.  In  such  cases  the  swelling  has  an 
appearance  similar  to  that  seen  in  angina  Ludovici.  In  severe  mixed 
infection  the  tissues  of  the  neck  may  become  gangrenous.  As  a  result 
of  such  severe  gangrenous  inflammation,  phlebitis  erosion  into  the 
veins  and  arteries  with  fatal  hemorrhage  may  result.  Retropharyn- 
geal abscess  or  retropharyngeal  adenitis  is  a  sequence  of  infection  of 
the  lymph-nodes.  The  retropharyngeal  abscess  in  such  cases  is  not 
as  benign  as  that  occurring  independently  of  scarlet  fever.  In  the 
latter  the  abscess  is  apt  to  involve  a  chain  of  retropharyngeal  nodes. 
Multiple  burrowing  abscesses  result.  The  nodes  of  the  mediastinum 
may  be  affected,  causing  empyema  or  pericarditis.  The  mediastinal 
abscess  may  cause  death  by  pressure  on  the  trachea,  or  by  eroding  the 
trachea,  burst  into  it  and  cause  death  through  suffocation. 


SCARLET  FEVER. 


Ill 


The  Mouth. — Stomatitis  always  occurs  in  severe  scarlet  fever.  It 
may  be  simply  a  mild  catarrhal  process.  If  there  is  a  pseudomem- 
branous formation  on  the  tonsils,  this  pseudomembrane  may  spread 
to  the  mucous  membrane  of  the  soft  palate,  and  the  buccal  mucous 
membrane  may  also  become  affected.  The  tongue  is  dry  and  fissured ; 
the  lips  are  dry,  fissured,  and  bleed  easily.  There  may  be  a  discharge 
of  necrotic  tissue  from  the  mouth.  The  soft  palate,  tonsils,  and 
pharynx  may  be  fused  into  a  necrotic  mass,  emitting  an  offensive  odor. 

Joints. — The  joints  become  inflamed  in  from  2  to  6  per  cent,  of 
the  cases  of  scarlet  fever.     This  affection  of  the  joints  has  been  called 


Fig.  39. 


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Boy  five  years  of  age,  observed  from  the  outset  of  the  disease.     Scarlet  fever  with  joint- 
complications.     No  cardiac  involvement.     Recovery. 

scarlatinal  rheumatism.  The  joint-affection  may,  in  exceptional 
cases,  precede  the  exanthema.  It  appears,  as  a  rule,  in  the  second 
or  third  week  of  the  disease  (Fig.  39),  and  is  therefore  one  of  the 
manifestations  seen  during  desquamation.  There  may  be  pain  in 
several  articulations.  In  other  cases  swelling  may  occur,  with  effu- 
sion of  serum  into  the  joints.  These  cases  retrograde.  There  may 
be  a  complicating  endocarditis.  In  other  cases  there  is  suppuration 
of  the  joint.  An  arthritis  with  streptococci  in  the  joint-effusion 
results.  The  streptococci  invade  the  joint  through  the  epiphyses  of 
the  bone,  and  produce  a  streptococcus  osteomyelitis  with  suppuration 
of  the  adjacent  joints  (Lannelongue,  Achard,  Koplik,  Van  Arsdale). 

As  a  rule,  suppuration  occurs  in  only  one  joint.  Cases  in  which 
several  joints  are  affected  are  generally  septic,  streptococci  having 
gained  access  to  -the  general  circulation  through  a  necrotic  focus  in 
the  throat  or  pharynx.  Such  cases  are  fatal.  There  are  metastases 
in  the  lungs,  kidneys,  pleura,  and  pericardium,  with  hemorrhages  in 
the  skin  and  enlargement  of  the  spleen.  Periarticular  abscesses 
rarely  occur  (Henoch).  The  prognosis  is  serious  in  all  suppura- 
tive cases. 

The  Kidneys. — In  scarlet  fever,  as  in  most  infectious  diseases, 
there  may  be  a  mild  form  of  nephritis  in  the  earlier  stages.  There 
are  a  small  amount  of  albumin  and  a  few  hyaline  casts  in  the  urine. 
This  nephritis  is  of  little  significance,  and  has  nothing  in  common 


278  THE  SPECIFIC  INFECTIOUS  DISEASES. 

with  the  severer  form  which  occurs  later  in  the  disease.  The  severe 
form  of  nephritis  begins  as  a  rule  in  the  third  week.  It  has  been 
known  to  appear  in  the  sixth  week.  The  frequency  of  this  compli- 
cation varies  in  different  epidemics.  In  some,  only  a  small  number 
of  cases  are  affected  (5  per  cent.).  In  other  epidemics  fully  70  per 
cent,  of  the  cases  are  thus  complicated.  Its  occurrence  cannot  always 
be  predicted  from  the  severity  of  the  disease.  The  mildest  cases  may 
develop  severe  nephritis.  The  diphtheritic  forms  of  angina  are  more 
likely  to  be  complicated  with  or  followed  by  nephritis.  On  the  other 
hand,  the  severest  forms  of  scarlet  fever  may  run  their  course  without 
marked  nephritis.  Sorensen  has  shown  that  at  autopsy  the  most 
marked  changes  may  be  found  in  the  kidneys,  although  no  clinical 
signs  of  the  affection  have  been  manifested  during  life.  In  50  per 
cent,  of  the  autopsies  upon  scarlet  fever  patients  Friedlander  found 
changes  in  the  kidneys.  It  was  formerly  thought  that  exposure  played 
an  etiological  role  in  this  affection,  but  this  view  has  been  abandoned. 

l^ephritis  may  develop  in  cases  which  have  been  very  carefully 
guarded  from  exposure  from  the  outset.  Although  the  symptoms  will 
be  detailed  elsewhere,  it  may  be  here  stated  that  the  first  symptom  is 
a  slight  oedema  about  the  eyes  and  face  which  spreads  to  the  rest  of 
the  body,  involving  the  trunk  and  extremities,  the  hands  and  dorsum 
of  the  feet,  and  the  scrotum.  In  some  cases  the  cedema  is  not  marked, 
in  others  the  anasarca  is  extreme.  The  serous  cavities  may  become 
the  seat  of  effusion,  and  there  may  be  hydrothorax,  hydropericardium, 
or  ascites. 

The  urine  also  shows  changes  very  early.  The  quantity  dimin- 
ishes very  rapidly,  or  it  may  be  completely  suppressed.  The  urine 
shows  the  presence  of  albumin,  rarely  more  than  0.5  per  cent.  It 
may  be  highly  colored  or  smoky,  or  may  be  distinctly  red  in  color, 
owing  to  the  large  amount  of  blood  and  blood-pigment  contained. 
The  urine  in  cases  of  partial  or  complete  suppression  generally  con- 
tains a  large  amount  of  albumin,  blood,  hyaline,  epithelium,  and 
blood-casts,  renal  epithelium,  and  leucocytes.  The  specific  gravity 
may  at  first  be  high,  1.030 ;  later,  when  diuresis  is  inaugurated,  it 
may  fall  to  1.006.  All  cases  do  not  run  a  course  with  anasarca. 
There  are  cases  without  this  symptom.  The  invasion  of  the  affection 
is  sometimes  marked  either  by  a  rise  of  temperature  or  convulsions. 

The  prognosis  is  good  in  spite  of  the  very  alarming  symptoms, 
such  as  convulsions  and  coma,  which  are  seen  in  some  cases.  This 
nephritis  usually  runs  its  course  in  from  four  to  six  weeks,  leaving 
the  kidneys  intact.  Sometimes  the  nephritis  apparently  subsides, 
but  albuminuria  of  a  very  mild  or  intermittent  form  persists  for 
months.  In  fact,  many  of  the  so-called  cases  of  paroxysmal  albumi- 
nuria are  probably  due  to  unobserved  scarlatinal  nephritis.     Finally, 


SC ABLET  FEVEB.  279 

there  are  cases  in  which  the  anasarca  recurs  at  long  intervals  as  a 
result  of  chronic  diffuse  nephritis. 

Vrcemia. — Ursemia  commonly  sets  in  with  a  diminution  in  the 
whole  quantity  of  urine  passed  daily.  It  may  supervene  without 
any  distinct  change  in  the  quantity  or  quality  of  the  urinary  excre- 
tion (Henoch).  In  these  cases  the  changes  in  the  urine  follow  the 
appearance  of  the  ursemic  symptoms.  Ursemia  may  also  appear  not- 
withstanding the  passage  of  an  increased  amount  of  urine.  The 
latter  mode  of  onset  in  ursemia  is  very  uncommon.  The  early 
symptoms  are  vomiting,  headache,  and  slight  twitching  of  the  facial 
muscles.  These  may  subside  with  the  abatement  of  the  nephritis. 
We  may  have,  however,  eclampsia  as  the  first  symptom,  with  tonic 
or  clonic  convulsions,  unconsciousness,  and  coma  with  temporary 
absence  of  the  reflexes.  The  respirations  are  increased,  and  in  most 
cases  the  temperature  rises.  The  pulse  is  small  and  the  skin  dry. 
The  convulsions  may  subside,  but  the  coma  may  continue.  The 
eclamptic  seizures  may  be  repeated.  The  ursemia  may  subside,  and 
after  a  very  protracted  interval  reappear  with  a  repetition  of  the 
above  phenomena.     Mania,  melancholia,  and  aphasia  may  ensue. 

Amaurosis  without  changes  in  the  retina  is  a  more  common  con- 
dition. The  retinitis  of  Bright's  disease  is  absent  in  scarlet  fever. 
Litten  found  a  swollen  condition  of  the  papilla.  Amaurosis  may 
persist  in  the  intervals  between  the  convulsions. 

The  heart  action  immediately  preceding  the  convulsions  is  slow. 
The  pulse  may  be  as  low  as  40  per  minute.  During  the  convulsions 
the  heart  action  is  increased.  The  respirations  may  be  60  and  the 
pulse  200  (Jlirgensen). 

The  temperature  may  be  100.4°-103°  F.  (38°-39.5°  C),  rarely 
10r.6°  F.  (42°  C),  with  an  initial  chill  (Jiirgensen). 

Ursemia  may  set  in  at  any  time  while  the  kidney  is  aifected. 

The  iJear^.— Myocarditis  of  an  acute  infectious  character  is  likely 
to  supervene  in  septic  cases  of  scarlet  fever.  The  changes  in  the 
myocardium  may  also  be  secondary  to  changes  in  the  pericardium 
and  endocardium. 

Endocarditis  of  the  cardiac  walls  is  more  frequent  than  that  of 
the  valves.  For  this  reason  murmurs  should  be  carefully  observed. 
]^o  conclusions  as  to  their  valvular  origin  can  be  reached  until  long 
after  convalescence.  Especially  is  this  true  of  murmurs  which  are 
heard  over  the  base  of  the  heart  and  pulmonic  orifice.  Endocarditis 
is  uncommon,  but  is  more  frequent  in  this  disease  than  in  diphtheria 
or  typhoid  fever. 

Pericarditis  is  rare.  Muscle  murmur  is  often  mistaken  for  it. 
If  present,  pericarditis  is  usually  of  the  dry  fibrinous  or  serofibrinous 
variety.  It  is  rarely  purulent,  except  in  cases  of  marked  purulent 
involvement  of  other  organs  and  cavities,  notably  the  pleura. 


280  THE  SPECIFIC  INFECTIOUS  DISEASES. 

Dilatation  of  an  acute  character  may  supervene  early  in  severe 
cases.  In  such  cases  v^e  may  have  tachycardia  or  bradycardia. 
There  may  be  cyanosis.  Sudden  death  is  very  rare  in  scarlet  fever. 
Friedlander  has  shown  that  in  scarlet  fever  with  marked  nephritis 
and  uraemia,  the  consequent  increased  arterial  tension  results  in  dila- 
tation of  the  left  ventricle,  with  slight  hypertrophy.  The  weight 
of  the  heart  is  increased  40  per  cent.  The  pulse  may  be  slow  and 
irregular.  As  the  nephritis  subsides  the  tension  diminishes  and  the 
frequency  of  the  pulse  increases.  Hypertrophy  being  the  result  of 
long-continued  increased  tension,  can  be  demonstrated  only  in  extreme 
cases.     Dilatation  is  rarely  so  great  as  to  cause  death. 

Lungs. — The  lungs  may  be  affected  by  pneumonia,  which  is  gen- 
erally of  the  bronchopneumonic  type.  Lobar  pneumonia  as  a  com- 
plication of  scarlet  fever  is  rare.  Gangrene  of  the  lung  may  occur  in 
the  severe  septic  cases. 

Pleura. — Pleuritis  as  a  complication  of  scarlet  fever  usually 
appears  in  the  middle  of  the  second  week.  It  is  commonly  of  the 
serous  variety,  but  the  author  has  had  many  cases  in  which  there 
was  an  empyema  usually  of  the  streptococcic  variety.  Flirbringer 
states  that  in  5  per  cent,  of  the  cases  of  pleurisy  there  is  nephritis. 

The  Blood. — There  is  a  diminution  of  the  haemoglobin,  which  is 
marked  in  cases  in  which  nephritis  is  present.  During  convalescence 
the  haemoglobin  increases.  Slight  leukocytosis  is  also  present  in  the 
course  of  the  disease.  Marked  leucocytosis  occurs  with  suppurative 
complications  such  as  otitis,  adenitis  or  empyema.  There  may  be 
purpura  and  surface  hemorrhages. 

Stomach  and  Intestine. — Vomiting  has  been  mentioned  as  an 
early  symptom  in  scarlet  fever.  It  is  sometimes  repeated  in  the 
course  of  the  disease  if  a  cough  due  to  any  laryngeal  or  pulmonary 
complication  exists.  Diarrhoea  is  sometimes  a  serious  corhplication. 
There  may  be  a  simple  diarrhoea,  in  which  an  excessive  number  of 
movements  may  threaten  the  life  of  the  patient  early  in  the  disease ; 
or,  on  the  other  hand,  the  diarrhoea  may  subside  without  serious 
results.  The  diarrhoea  may  take  on  a  dysenteric  or  typhoidal  type, 
with  severe  hemorrhages  from  the  gut.  There  are  some  forms  of 
diphtheria  of  the  pharynx,  stomach,  and  large  intestine  in  the  septic 
types  of  scarlet  fever  which  have  been  described  by  Litten. 
Sequelae. — As  sequelae  to  scarlet  fever  may  be  mentioned : 
Anaemia. — This  may  persist  for  some  time. 

Glandular  Swellings. — The  lymph-nodes  at  the  angle  of  the  jaw 
are  apt  to  remain  enlarged  long  after  convalescence.  The  tonsils 
may  remain  large. 

Tuberculosis. — Tuberculosis  may  follow  scarlet  fever.  It  cannot 
be  said  that  there  is  any  distinct  connection  between  the  two  diseases. 


SCARLET  FEVEB.  28  L 

Scarlet  fever  may  leave  the  patient  more  susceptible  to  infection 
either  of  acute  miliary  or  chronic  tuberculosis. 

Nervous  Diseases. — Chorea  has  been  noted  by  Gerhardt  to  follow 
scarlet  fever,  as  have  also  rheumatic  joint-affections  v^ith  endocarditis. 

Facial  paralysis  may  occur  as  the  result  of  prolonged  otitis. 

Psychoses,  such  as  melancholia  and  mania,  have  been  noted, 
similar  to  those  foUov^ing  typhoid  fever  or  pneumonia. 

Otitis. — Otitis  may  remain  with  a  permanent  discharge  and  con- 
sequent deafness  or  mutism. 

Relapses  or  Second  Attacks.- — There  are  no  relapses  in  the  true 
sense  in  scarlet  fever,  but  instances  occur  in  which  after  the  primary 
eruption  has  faded  a  new  and  general  scarlatinous  rash  appears.  In 
others,  the  disease  runs  an  exceedingly  mild  course,  the  rash  is  evanes- 
cent and  lasts  only  a  short  time,  and  the  temperature  falls  quickly 
to  the  normal.  After  ten  to  fourteen  days,  a  rise  of  temperature 
occurs,  the  lymph-nodes  at  the  angle  of  the  jaw  enlarge  and  the  tonsils 
also  enlarge  and  become  covered  with  a  pseudomembrane.  The 
temperature  is  quite  high.  Albuminuria  and  nephritis  of  a  severe 
type  may  appear  at  this  time.  Second  and  third  attacks  of  scarlet 
fever  are  found  recorded  in  the  literature.  I  have  not  seen  any  in 
which  I  have  personally  diagnosed  two  attacks.  The  suspicion 
always  is  present  that  in  these  cases  rotheln  may  have  been  diagnosed 
as  scarlet  fever. 

Diagnosis.- — The  diagnosis  of  scarlet  fever  in  most  cases  presents 
few  difficulties;  but  there  is  no  disease  in  which  the  symptoms  are 
more  indefinite  at  times.  This  is  particularly  so  with  patients  who 
present  an  evanescent  or  partial  exanthema  and  only  slight  febrile 
disturbance.  In  some  cases  the  diagnosis  must  always  remain  in 
doubt.  Under  these  conditions  it  is  better  to  err  on  the  safe  side, 
and  to  take  all  precautions  of  isolation.  The  exanthema  if  partial 
or  not  very  well  marked  is  likely  to  be  overlooked.  The  angina, 
which  is  the  most  constant  symptom,  may  be  mild.  The  temperature 
presents  nothing  typical  as  in  typhoid  fever. 

It  is  good  practice  in  the  presence  of  a  localized  exanthema  of  a 
punctate  character  on  the  thighs  or  lower  abdomen  or  the  upper  part 
of  the  chest,  with  angina  and  a  slight  febrile  movement,  to  consider 
the  case  as  one  of  scarlet  fever.  In  all  cases  of  sore  throat  it  is  wise 
not  to  omit  an  inspection  of  the  general  surface.  Although  some 
authors  have  described  the  angina  of  scarlet  fever  as  typical  in  color, 
the  author  has  never  found  this  sign  of  value.  In  some  cases  of 
scarlatinal  angina  the  throat  is  intensely  red ;  in  other  cases  it  is  of  a 
pale-pink  hue;  in  still  others  the  throat  is  only  slightly  inflamed. 

Enanthema. — The  enanthema  is  not  of  any  service  in  making  a 
diagnosis.  The  eruption  on  the  soft  and  on  the  hard  palate  is  not 
characteristic. 


282  THE  SPECIFIC  INFECTIOUS  DISEASES. 

Albumin. — Albumin  in  the  urine  is  thought  by  some  to  be  diag- 
nostic of  scarlet  fever.  There  may  be  marked  and  unmistakable 
symptoms  of  scarlet  fever  without  albuminuria.  A  simple  lacunar 
amygdalitis  may  be  accompanied  by  albuminuria. 

Differential  Diagnosis. — We  must  differentiate  the  eruption  of 
scarlet  fever  from  that  of  measles  and  rotheln,  from  drug  eruptions, 
and  those  due  to  irritants. 

Measles. — In  some  forms  of  scarlet  fever  the  eruption  on  the 
forearms  has  a  blotchy  appearance.  ISTear  the  wrist-joint  the  author 
has  seen  it  closely  resemble  the  eruption  of  measles.  In  these  cases 
the  punctate  character  of  the  eruption  elsewhere  on  the  surface,  and 
the  presence  of  angina,  will  assist  us,  in  the  absence  of  any  enan- 
thema  on  the  buccal  mucous  membrane  ('' Koplik's  spots")  (Plate 
XIV.),  in  coming  to  a  conclusion.  In  measles  the  diffuse  localization 
of  the  exanthema  on  the  face,  the  conjunctivitis  and  bronchitis,  will 
aid  us.  In  scarlet  fever  parts  of  the  face,  such  as  the  alse  nasi  and  the 
region  of  the  mouth,  are  free  from  eruption,  while  in  measles  these 
localities  are  affected  by  the  exanthema. 

Rotheln. — Scarlet  fever  is  most  frequently  mistaken  for  rotheln, 
and  vice  versa. 

In  rotheln,  when  the  eruption  is  punctate,  it  is  invariably  dis- 
crete. There  is  never  the  severe  dermatitis  vdth  swelling  of  the 
skin  found  in  scarlet  fever.  In  rotheln  the  lymph-nodes  are  more 
constantly  and  generally  swollen  behind  the  sterno-mastoid,  in  the 
axillae  and  groin.  The  throat  is  but  slightly  reddened.  Eotheln 
presents  a  normal  temperature  or  at  most  a  temperature  at  the  outset 
of  the  eruption  of  101°-102°  F.  (38.3°-38.8°  C.)  or  even  103°  F. 
(39.4°  C),  which  rapidly  subsides  to  the  normal,  although  the  exan- 
thema may  be  spreading. 

Drug  Eruptioris. — Following  the  administration  of  quinine  chil- 
dren develop  an  eruption  which  closely  resembles  that  of  scarlet  fever. 
In  the  presence  of  an  angina  and  fever  it  may  be  difficult  to  exclude 
scarlet  fever.  Antitoxin  of  diphtheria,  antipyrin,  and  belladonna 
also  cause  a  rash  closely  resembling  that  of  scarlet  fever.  It  is  well 
in  such  cases  to  discontinue  the  drug,  and  after  a  few  days,  the  erup- 
tion having  disappeared,  to  administer  it  again.  If  the  patient  be 
susceptible,  there  will  be  a  repetition  of  skin  symptoms.  Kerosene 
rubbed  on  the  surface  will  cause  a  punctate  eruption  the  exact  coun- 
terpart of  a  scarlet  fever  eruption.  Among  the  poor,  with  whom 
petroleum  is  popular  as  a  general  remedy,  this  should  be  borne  in 
mind.  If  that  has  been  the  case,  the  skin  will  have  a  distinct  odor 
of  kerosene. 

Prognosis. — The  prognosis  in  scarlet  fever  varies  largely  with  the 
character  of  the  epidemic  and  the  prevalent  type  of  the  disease.     In 


SCAELET  FEVEB.  283 

some  epidemics  in  Kew  York  City  the  mortality  has  been  exceed- 
ingly low — 2  to  4  per  cent.  (J.  L.  Smith),  while  in  others  it  has 
been  notably  high.  In  England  the  mortality  varies  from  13  to  40 
per  cent. 

Personal  idiosyncrasy  will  affect  the  prognosis.  Some  children 
develop  malignant  septic  types  of  the  disease  although  the  prevailing 
epidemic  is  mild. 

Cases  complicated  with  severe  angina  septic  in  character  do  badly 
from  the  outset. 

ISTephritis  is  a  complication  greatly  to  be  feared.  It  may  result 
in  uraemia  and  death,  or  the  acute  may  be  followed  by  a  chronic 
nephritis  which  may  ultimately  prove  fatal. 

Otitis  may  cause  serious  and  even  fatal  complications,  such  as 
brain  abscess  or  sinus  thrombosis. 

Affections  of  the  endocardium  or  pleura  may  prove  fatal. 

The  prognosis  of  the  so-called  scarlatinal  rheumatism  is  good. 
The  joints,  even  if  synovitis  develops,  retrograde  as  a  rule  to  the 
normal  in  from  two  to  three  weeks.  This  may  result  even  if  high 
fever  persists  for  some  time  during  the  joint-affection.  In  the  pres- 
ence of  joint-complications  it  is  necessary  to  be  on  the  lookout  for 
endocarditis  or  pericarditis.  The  occurrence  of  the  latter  takes  place, 
as  a  rule,  in  cases  in  which  there  are  other  signs  of  septic  infection, 
such  as  pleuritis  and  even  peritonitis.  These  are  cases  of  mixed 
infection.  If  synovitis  is  complicated  vdth  such  a  serious  inflamma- 
tion as  pericarditis,  the  latter  is  very  likely  to  be  purulent  and  in  that 
case  the  prognosis  is  grave. 

The  patient  cannot  be  said  to  be  out  of  danger  until  the  fourth 
week  of  the  disease  has  passed  without  serious  complications.  A  very 
high  temperature  at  the  outset  is  an  element  of  danger,  although  not 
necessarily  so.  Septic  cases  with  high  temperature  and  pulse  above 
150  in  the  first  week  of  the  disease  are  always  to  be  regarded  with 
apprehension. 

Lotz  shows  that  the  mortality  is  greatest  under  the  age  of  one 
year  and  between  the  first  and  second  years.  The  lowest  mortality 
according  to  statistics  occurs  between  the  tenth  and  the  fifteenth  years. 

Morbid  Anatomy. — Skin. — The  investigations  of  Preobrachensky 
and  Pearce  show  that  during  the  interval  from  the  third  day  to  the 
fourth  week  certain  changes  occur  in  the  skin.  These  consist  chiefly 
in  an  erythematous  inflammation  of  the  papillary  layer,  with  hyper- 
semia,  hemorrhages,  and  a  diapedesis  of  erythrocytes  and  leucocytes. 
There  is  an  oedematous  infiltration  of  the  connective  tissue  of  the  skin. 
The  cells  of  the  rete  Malpighii  show  vacuolization.  There  is  also  an 
infiltration  of  the  sudoriparous  and  sebaceous  glands  with  small  round 
cells.     The  epithelium  of  these  glands  desquamates  and  necroses. 


284  THE  SPECIFIC  INFECTIOUS  DISEASES. 

At  the  time  of  the  eruption  streptococci  are  found  in  the  skin,  espe- 
cially in  the  vesicles  of  the  sudamina. 

The  changes  in  the  kidneys  will  be  considered  in  the  chapter  on 
Diseases  of  the  Kidney. 

Bacteriology. — The  parasitic  nature  of  scarlet  fever  is  still  a 
matter  for  study.  Streptococci  play  a  leading  role  in  the  disease. 
Micro-organisms  have  been  described  in  the  blood  (Hallier,  Klebs, 
Tschamer) .  Others  have  seen  plasmodium-like  protozoa  in  the  blood 
(Pfeiffer,  Doehle).  Pearce  concludes  that  the  bacteria  vt^hich  pro- 
duce secondary  infections  are  the  Streptococci,  Staphylococci  and 
Pneumococci  in  order  of  frequency  as  named. 

Streptococci  have  been  found  in  the  throat  membranes  (Loffler), 
in  the  joints  (Litten,  Heubner,  Koplik,  Van  Arsdale),  and  in  various 
viscera  (Frankel,  Freudenberg) .  Streptococci  have  also  been  found 
in  purulent  foci  of  the  joints  and  pleura  (Raskin),  and  in  the  kid- 
neys, in  cases  which  have  succumbed  to  fatal  nephritis  (Babes).  In 
septic  forms  of  scarlet  fever  these  streptococci  exist  in  the  circulating 
blood  (Babes,  Lenhartz,  Peer).  Streptococci  have  also  been  found 
in  the  cerebrospinal  fluid  and  bone-marrow  (Baginsky).  Bacteriol- 
ogists, however,  are  not  willing  to  assign  to  these  streptococci  anything 
but  a  secondary  role,  because  they  present  no  features  which  distin- 
guish them  from  ordinary  Streptococcus  pyogenes.  Kurth  found  that 
some  of  the  streptococci,  the  so-called  conglomerate-forming  strepto- 
cocci, were  of  a  virulent  type.  The  more  important  complications, 
such  as  pneumonia,  otitis,  adenitis,  pleuritis,  disease  of  the  antrum 
of  Highmore,  abscess  of  the  lung  and  kidney,  endocarditis  and  inflam- 
mation of  the  sphenoidal  sinuses  are  caused  by  Streptococci  (Pearce). 

Bretonneau,  Henoch,  and  Heubner  have  always  distinguished  the 
diphtheria  of  scarlet  fever  from  true  diphtheria.  Sorensen  describes 
the  membranous  formations  of  scarlet  fever  as  milky,  yellow,  smeary 
deposits  which  cannot  be  peeled  from  the  parts.  The  membrane 
seems  to  penetrate  into  the  mucous  surfaces.  Ulcers  form,  and  the 
tonsils,  soft  palate,  uvula,  and  nasopharynx  become  a  necrotic,  slough- 
ing mass.  Scarlatinal  diphtheria  is  pre-eminently  a  septic  inflam- 
matory process  with  high  fever,  swelling  of  the  lymph-nodes,  and 
suppurations  in  dift'erent  parts  of  the  body.  If  the  larynx  and 
trachea  are  affected,  the  bronchi  rarely  become  involved.  The  con- 
trary is  true  of  Lofller  diphtheria.  In  the  latter  the  membrane  can 
be  peeled  from  the  surface  of  the  mucous  membrane.  The  membrane 
is  rich  in  fibrin,  and  spreads  more  on  the  surface  and  not  in  the 
depths.     True  diphtheria  is  followed  by  paralyses. 

The  lesions  of  the  gastro-intestinal  tract  are  degeneration  with 
proliferation  of  epithelium  and  invasion  of  leucocytes.  In  the  heart 
there  is  myocarditis  with  fatty  degeneration,  in  the  liver  focal  necrosis 


SCABLET  FEVEE.  285 

and  leucocytic  invasion.  In  the  spleen  there  is  endothelial  prolifera- 
tion, abundant  formation  of  plasma-cells  and  leucocytic  invasion. 
The  kidneys  most  frequently  shov^  acute  interstitial  nephritis.  The 
so-called  plasma-cells  of  Councilman  are  found  in  the  lymph-nodes, 
kidneys,  spleen  and  tissues  (Pearce). 

Prophylaxis. — The  diagnosis  of  scarlet  fever  once  made,  the  pa- 
tient should  be  isolated  from  the  rest  of  the  family.  If  several  chil- 
dren are  affected  in  the  same  family,  these  children  should  be  sepa- 
rated and  not  placed  in  one  room.  Otherwise  reinfections  will  occur. 
The  clothes  worn  just  prior  to  the  illness  should  be  sterilized  in  steam 
and  then  aired  in  the  sun.  Sufferers  with  angina  who  have  been 
about  the  patient  should  not  be  allowed  to  come  in  contact  with  the 
healthy.  All  the  children  of  the  family  should  be  kept  from  school. 
During  the  illness  the  bedclothes  and  linen  of  the  patient  should  be 
put  into  a  1 :  5000  solution  of  mercuric  chloride,  prior  to  being  boiled 
and  dried  and  aired  in  the  sun.  The  sick-room  must  be  kept  well 
ventilated.  There  is  no  advantage  in  keeping  the  temperature  of  the 
sick-chamber  too  low.  The  author  has  found  a  temperature  of  68° 
F.  (20°  C.)  comfortable  for  the  patient  and  those  about  him.  Sun- 
shine and  fresh  air  are  of  more  value  than  a  room  uncomfortably  cool. 
If  possible,  it  is  well  to  spray  with  some  simple  cleansing  solution 
morning  and  evening  the  throats  of  any  children  of  the  family  who 
are  not  affected. 

The  physician  should  take  off  his  coat  and  vest  and  put  on  a 
linen  robe  of  some  kind  before  entering  the  sick-room.  On  his 
departure  he  should  leave  this  robe  outside  the  sick-room,  or,  better 
still,  outside  the  window  of  an  adjacent  room.  If  the  physician 
wears  a  beard,  he  should  wash  his  face  in  a  1 :  2000  solution  of 
mercuric  chloride  after  leaving  the  patient.  The  hands  should  also 
be  scrupulously  disinfected.  When  he  returns  home  he  should  make 
a  complete  change  of  clothing  before  visiting  other  patients.  Carpets 
and  superfluous  furniture  should  be  removed  from  the  sick-room. 
The  hanging  of  sheets  wet  with  disinfectants  in  the  door  of  the  sick- 
room is  not  essential. 

Those  about  the  sick  should  have  no  intercourse  with  the  healthy, 
nor  should  they  go  through  the  house.  Meals  should  be  carried  by 
others  to  some  neutral  spot. 

After  convalescence  the  question  of  the  disinfection  of  the  sick- 
room and  its  occupation  by  others  arises.  It  must  be  confessed  that 
at  present  we  are  in  possession  of  no  absolutely  sure  method  of  dis- 
infecting a  room  after  its  occupancy  by  a  scarlet  fever  patient.  We 
may  adopt  one  of  two  methods.  The  cracks  and  spaces  in  the  win- 
dows and  doors  are  closed  with  strips  of  paper  glued  over  them.  The 
disinfectants,  preferably  a  large  quantity  of  binoxide  of  manganese. 


286  TRE  SPECIFIC  INFECTIOUS  DISEASES. 

table  salt,  and  sulphur,  are  placed  in  the  centre  of  the  room.  The 
sulphur  is  then  ignited  and  the  doors  sealed.  Formalin  is  also 
effective.  After  twenty-four  hours  the  room  is  opened  and  aired, 
and  the  floors  and  walls  are  scrubbed  with  1 :  2000  corrosive  subli- 
mate. In  hospitals  the  scrubbing  is  sufficient.  The  floor  and  walls 
about  the  bed  occupied  by  the  patient  are  scrubbed,  and  also  the  bed. 
The  mattresses  are  steamed  in  a  sterilizer  constructed  for  the  purpose. 
In  families  it  is  best  to  destroy  or  burn  all  bedding  of  hair.  Eugs 
may  be  aired  and  disinfected  by  steam  at  the  establishments  equipped 
for  the  purpose. 

How  soon  may  a  scarlet  fever  patient  have  intercourse  with  the 
healthy?  We  have  no  exact  data  on  this  important  point.  Some 
authors  advise  that  after  the  termination  of  desquamation  the  patient 
be  given  a  bath  of  1 :  10,000  corrosive  sublimate,  and  then  allowed  to 
mingle  with  the  healthy.  Others  (Baginsky)  advise  prolonged  isola- 
tion. It  is  not  always  practicable,  nor  indeed  desirable,  to  isolate  a 
patient  for  too  long  a  period.  Family  considerations  demand  a  return 
to  the  family  circle  as  soon  as  possible.  In  these  cases  the  course  first 
mentioned  is  the  most  practicable.  In  cases  which  have  exhibited  a 
malignant  septic  form  of  the  disease  the  author  would  advise  pro- 
longed isolation  after  convalescence,  for  the  safety  of  the  other  chil- 
dren. The  urine  of  a  scarlatinal  case  if  there  are  even  mild  signs  of 
nephritis,  such  as  albumin  and  casts,  is  believed  to  be  infectious.  A 
recent  otitic  discharge  is  thought  to  be  capable  of  conveying  the  scar- 
latinal poison. 

Treatment. — The  treatment  of  scarlet  fever  is  largely  symptomatic. 
In  an  ordinary  mild  case  there  is  little  to  do  but  to  regulate  the  diet, 
and  keep  the  nose  and  throat  freed  from  excess  of  secretion. 

The  diet  should  consist  mostly  of  milk,  matzoon,  junket,  malted 
milk,  cream  and  water;  later  on  farinaceous  gruels,  cream  soups, 
bread,  toast  and  milk.  Water  should  be  freely  given  at  frequent 
intervals. 

The  skin  needs  a  little  care.  During  desquamation  it  is  anointed 
once  a  day  with  a  1  per  cent,  salicylic  acid  or  boric  acid  ointment,  to 
be  stopped  after  the  first  week.  If  there  is  pruritus  the  following 
lotion,  recommended  by  Kellogg,  is  useful : 

Calamine 3j  4.00 

Zinc  oxide 3  ss  2.00 

Aqua  rosae 5  j  30.00 

Glycerin HI  xv  1.00 

The  urine  should  be  examined  daily,  for  even  in  the  mildest  cases 
severe  nephritis  is  apt  to  intervene.  Vigilance  should  not  be  relaxed 
until  after  the  fourth  week. 


SCABLET  FEVER.  287 

The  fever  in  simple  cases  needs  only  the  mildest  measures.  We 
should  remember  that  the  tendency  of  the  fever  is  to  mount  until  the 
eruption  is  fully  developed.  It  then  naturally  remits.  Thus  a  tem- 
perature of  105°  F.  (40.5°  C.)  in  an  ordinary  uncomplicated  case 
may  not  last  more  than  a  few  hours.  In  ordinary  cases  sponging 
with  lukewarm  water  is  efficacious.  The  aim  is  not  so  much  to 
reduce  the  temperature  as  to  support  the  nervous  system  and  the 
heart.  In  private  practice  it  is  well  not  to  resort  at  once  to  full  baths 
simply  because  the  temperature  is  above  104°  F.  (40°  C).  The 
reverse  is  true  with  temperatures  which  are  persistently  high  for  days. 
In  such  cases  the  author  resorts  to  full  baths.  The  patient  is  placed 
in  a  bath  at  100°  F.  (37.'7°  C),  and  the  water  cooled  to  85°  F. 
(29.4°  C).  With  children  it  is  well  not  to  resort  to  lower  tempera- 
tures. This  is  especially  true  in  the  asthenic  forms  of  sepsis.  The 
patients  fail  to  react  after  the  bath,  and  seem  weakened  by  the  exces- 
sive cold.  The  patients  remain  in  the  bath  about  five  minutes,  and 
are  then  taken  out.  In  cases  in  which  the  temperature  mounts  above 
105°  F.  (40.5°  C.)  we  may  employ  the  pack  at  a  temperature  of  70° 
F.  (21.1°  C),  with  much  benefit  if  the  reaction  is  good.  The  trunk 
pack  may  be  repeated  every  one  or  two  hours.  The  baths  above 
described  may  be  given  every  four  hours.  While  the  patients  are  in 
the  bath  reaction  may  be  promoted  by  mild  friction.  Patients  with 
scarlet  fever,  especially  young  children,  do  not  bear  baths  below  75° 
F.  (23.8°  C.)  well.  The  old  theory  that  kidney  complications  are 
caused  by  cold  baths  is  not  proved.  On  the  contrary,  in  uraemia 
Kussmaul  lays  much  weight  on  the  beneficial  effects  of  cold  packs 
where  hot  baths  produce  untoward  symptoms  (Baruch). 

Antipyretics. — Antipyretics  are  of  little  value  in  scarlet  fever, 
and  should  not  be  used  unless  there  is  some  special  contraindication 
against  hydrotherapy.  Antipyretics  of  the  coal-tar  series  especially 
weaken  the  heart  in  the  toxaemia  which  accompanies  scarlet  fever. 

Heart. — The  heart  is  supported  in  septic  cases  with  high  tempera- 
ture, in  the  same  manner  as  in  other  diseases  of  a  toxic  nature. 
Alcohol  (whiskey)  is  not  given  in  mild  cases.  In  considering  its 
administration  the  kidneys  should  be  taken  into  account.  We  wait 
until  the  temperature  remains  persistently  high.  At  the  third  or 
fourth  day  a  constant  temperature  of  105°  F.  (40.5°  C.)  which 
refuses  to  abate  vdth  treatment  calls  for  the  employment  of  alcohol 
vdth  other  remedies.  For  a  child  of  from  two  to  five  years  half  a 
drachm  to  a  drachm  of  alcohol  every  three  hours  is  a  sufficient  dose. 
Alcohol  and  digitalis  are  probably  our  best  cardiac  remedies.  Caf- 
feine and  camphor  may  also  be  employed.  Strychnine  does  not  seem 
to  do  so  well  in  cases  in  which  there  is  an  active  myocarditis. 

Throat  and  Nose. — In  inflammations  of  these  passages  we  simply 


288  TSE  SPECIFIC  INFECTIOUS  DISEASES. 

keep  the  parts  sprayed  with  an  alkaline  solution  in  order  to  remove 
excessive  secretion.  In  this  way  the  patient  is  made  comfortable  and 
the  inflammation  of  the  fauces  kept  within  bounds.  It  is  not  always 
possible  to  spray  the  throats  of  the  little  ones.  If  there  is  nasal 
involvement,  the  passages  may  be  kept  clear  by  syringing  with  salt 
solution  in  the  manner  as  described  by  Kellogg  and  in  vogue  at  the 
Minturn  Hospital,  ISTew  York. 

The  patient,  protected  by  a  rubber  sheet,  is  turned  on  one  side 
with  the  cheek  resting  on  the  edge  of  a  pus  basin,  and  the  head  is 
lowered  slightly  by  removing  the  pillow,  (Infants  are  prepared  as 
for  intubation  by  wrapping  them  from  the  shoulders  to  the  feet  in 
a  strong  sheet  fastened  firmly  at  the  shoulders,  elbows,  wrists,  knees, 
and  ankles.)  A  fountain  or  Davidson  soft  rubber  bulb  syringe  is 
used.  The  straight  tip  of  the  syringe  is  introduced  into  the  mouth 
in  the  median  line  and  carried  back  to  the  base  of  the  tongue,  which 
is  held  down  so  as  to  expose  the  back  of  the  throat.  The  solution  is 
then  directed  with  considerable  force  against  the  pharynx,  or  the  part 
of  the  throat  from  which  we  wish  to  dislodge  the  membrane.  When 
the  mouth  is  filled,  the  tube  is  compressed  with  the  finger,  and  the 
patient  is  allowed  to  expel  the  solution  into  the  basin.  This  procedure 
is  repeated  until  the  treatment  is  finished.  Strong  antiseptic  solu- 
tions or  solutions  of  sublimate  or  peroxide  of  hydrogen  are  of  little 
use  if  not  harmful.  Antitoxin  of  diphtheria  is  employed  if  true 
Loffler  diphtheria  coexists.  In  the  streptococcic  or  most  common 
form  of  pseudomembranous  inflammation  we  have  no  remedy  which 
acts  directly  on  the  inflammation.  Antistreptococcic  serum  has  not 
given  encouraging  results. 

In  those  cases  of  scarlet  fever  in  which  there  is  great  obstruction 
of  the  nasal  passages  and  enlargement  of  the  tonsils,  with  spreading 
of  diphtheritic  membrane  from  the  tonsil  to  the  nasal  pharynx  and 
posterior  nares,  there  is  great  difficulty  in  breathing.  It  is  almost 
impossible  in  some  cases  to  cleanse  the  nares  on  account  of  the  accu- 
mulation of  secretion  and  pseudomembrane.  The  patient  lies  in  a 
semi-soporose  state.  The  lymph-nodes  at  the  angle  of  the  jaw  are 
greatly  enlarged.  This  condition  of  affairs  may  set  in  from  the  very 
onset  of  the  disease.  In  these  cases  the  problem  arises  of  relieving 
the  difficulty  of  breathing.  Any  interference  in  a  surgical  way  with 
the  tonsil  would  be  dangerous  to  the  patient  at  this  time. 

Two  courses  are  open  to  us :  We  may  intube  the  nostrils  with  a 
piece  of  soft-rubber  catheter  tubing,  each  nostril  being  intubed  with 
a  piece  of  soft-rubber  catheter,  extending  backward  toward  the  pos- 
terior wall  of  the  nasal  pharynx.  !N"os.  10  to  12  are  the  most  avail- 
able calibres  of  tubing.  The  pieces  of  rubber  tubing  are  secured 
externally  with  safety-pins,  being  cut  close  to  the  external  nares. 


SCABLET  FEVEB.  289 

Through  these  tubes  the  posterior  nasal  space  can  be  cleansed  by 
cautiously  allowing  some  salt  solution  to  run  through  the  rubber 
tubing  (l^orthrup).  The  relief  in  some  cases  is  instantaneous;  in 
others  the  amount  of  secretion  is  so  great  as  to  block  up  the  rubber 
tubing.  There  is  then  no  other  resource  but  to  remove  the  tubing 
and  to  instil  in  each  nostril  3  to  5  drops  of  a  1 :  1000  solution  of 
adrenalin  chloride  three  or  four  times  daily.  The  relief  from  this 
remedy  is  very  great  in  some  cases.  I  have  seen  the  breathing  re- 
lieved at  once.  At  the  same  time,  owing  to  the  fact  that  adrenalin 
is  a  cardiac  stimulant,  the  patient  is  rather  supported  as  well  as 
relieved  by  this  remedy.  Its  effect  should,  however,  be  closely 
watched.  We  should  be  very  cautious  in  these  cases  not  to  irrigate 
the  nostrils  either  too  often  or  too  forcibly,  on  account  of  the  danger 
of  ear  complications,  but  should  try  every  measure  before  resorting 
to  irrigation.  ISTasal  irrigation  is  carried  out  in  a  manner  similar  to 
that  pursued  in  attacks  of  true  diphtheria  in  the  same  situation. 

Lymph-nodes. — The  lymph-nodes,  especially  in  the  region  of  the 
angle  of  the  jaw,  are,  if  swollen,  treated  with  local  cold  applications, 
with  inunction  of  ichthyol  or  unguentum  Crede  underneath  the  cold 
applications.  This  frequently  affords  much  relief.  Unless  distinct 
fluctuation  exists,  we  should  avoid  incision  of  the  lymph-nodes  of  the 
neck.  The  author  has  seen  these  nodes  incised  at  the  beginning  of 
the  second  week  in  septic  cases,  with  very  unsatisfactory  results. 
Pus  is  not  found  in  such  cases,  but  only  foci  of  necrosis,  which  are 
best  left  to  nature  until  the  patient  regains  strength.  Later  in  the 
disease  such  nodes  may  suppurate  and  need  incision. 

Nephritis. — The  treatment  of  nephritis  is  elsewhere  described  in 
detail.  The  lines  of  procedure  are  indicated  here.  As  a  prophy- 
lactic against  the  occurrence  of  nephritis  the  early  exhibition  of 
urotropin  in  doses  of  three  to  five  grains,  three  times  daily,  is  con- 
sidered of  great  value.  Headache,  vomiting,  and  convulsions  are 
treated  with  hot  baths,  and  by  the  continuous  irrigation  of  hot  saline 
solution  (Kemp)  per  rectum.  The  kidneys  are  apt  to  be  affected 
from  the  outset  in  malignant  cases.  In  these  cases  the  Kemp  treat- 
ment with  saline  enemata  is  most  suitable.  With  young  or  intract- 
able children  the  continuous  irrigation  of  Kemp  cannot  be  carried 
out.  In  these  cases  a  high  rectal  enema  of  normal  saline  solution  is 
given  twice  daily  or  more  often  if  necessary.  If  general  anasarca  is 
present,  the  patient  is  given  two  warm  baths  daily;  or  with  aid  of 
hot  air  diaphoresis  may  be  facilitated  by  wrapping  him  in  a  blanket 
which  has  been  moistened  with  hot  water  and  then  wrung  dry.  Digi- 
talis in  the  form  of  infusion  is  the  most  efficient  remedy,  combined 
with  moderate  doses  of  potassium  acetate,  tartrate,  or  citrate.  Milk 
is  the  exclusive  diet. 

19 


290  TEE  SPECIFIC  INFECTIOUS  DISEASES. 

Complete  suppression  of  urine,  with  blood  and  all  the  anatomical 
elements  of  severe  inflammation  of  the  kidney,  will  sometimes  be 
followed  by  an  increased  amount  of  urine.  In  such  cases  the  treat- 
ment just  indicated  will  not  be  efficacious.  The  heart  must  be  sup- 
ported, and  watch  kept  for  ursemic  symptoms.  Opium  should  be 
employed  with  extreme  caution — best  not  at  all  in  convulsions; 
chloroform  inhalations  with  chloral  per  rectum  are  preferable.  Saline 
enemata  at  108°  F.  (42.2°  C),  diuretin,  and  nitroglycerin  are  appli- 
cable in  those  cases  in  which  there  is  suppression  of  urine. 

Otitis. — Otitis  is  sometimes  first  indicated  by  spontaneous  per- 
foration and  purulent  discharge.  In  other  cases  pain  with  a  sharp 
rise  of  temperature  will  indicate  inflammation  of  one  or  both  ears. 
Paracentesis  is  best  performed  early,  even  if  only  slight  redness  of 
the  drum  is  present.  Later  in  the  disease  (fifth  or  sixth  week)  both 
ears  may  continue  to  discharge  profusely,  with  an  evening  rise  of 
temperature.  In  some  cases  the  author  has  noted  slight  frontal  head- 
ache and  drowsiness  toward  evening.  There  may  be  only  a  slight 
redness  over  the  mastoid  of  one  or  both  ears.  It  is  best  not  to  tem- 
porize in  such  cases,  but  to  advise  opening  the  mastoid  process  to 
insure  drainage  and  avoid  sinus  thrombosis  or  cerebral  abscess. 

Complications  in  the  lung,  such  as  bronchopneumonia,  are  treated 
on  general  lines.  The  possibility  of  the  occurrence  of  pleurisy  should 
not  be  lost  sight  of.  Extensive  effusions  must  be  aspirated.  In  all 
forms  of  pleurisy,  even  if  the  amount  of  fluid  is  not  large,  but  per- 
sists, with  a  rise  and  fall  of  temperature,  a  needle  should  be  intro- 
duced into  the  chest  to  determine  the  nature  of  the  fluid.  Pus  should 
be  evacuated  from  the  pleura  in  the  manner  directed  in  the  chapter 
on  Empyema. 

Joints. — Joint-affections  are  best  treated  by  immobilizing  the 
affected  articulations.  The  patient  should  be  kept  quiet,  and  sodium 
salicylate  in  liberal  doses  administered.  If  this  is  ineffectual  after 
a  few  days,  the  joints  should  be  wrapped  in  cotton  moistened  with 
oil  of  wintergreen,  and  sodium  salicylate  combined  with  sodium 
bicarbonate  given  in  very  liberal  doses  (aa  grains  iv  (0.4)  for  a  child 
of  three  or  four  years,  four  times  daily).  It  synovitis  occurs  and  the 
fever  continues  high,  the  joint  should  be  aspirated  under  antiseptic 
precautions,  in  order  to  ascertain  if  pus  is  present.  If  this  is  the 
case,  an  incision  with  drainage  is  the  proper  remedy. 

Serum  Treatment.  —  The  serum  treatment  of  scarlet  fever  by 
means  of  a  polyvalent  streptococcus  serum  has  recently  been  favor- 
ably reported  by  Escherich,  Moser,  Bokai  in  Europe  and  Charlton  in 
America.  The  difficulty  of  preparing  such  a  serum  has  as  yet  pre- 
vented its  general  adoption. 


EOTHELN.  291 

ROTHELN. 

(German  Measles;  Bubella;  Trousseau's  Eoseola.) 

Epidemics  of  this  disease  have  been  described  by  Forney,  1784; 
Heim,  1812;  Hildebrand,  1832;  and  in  recent  times  by  Thomas 
Smith  and  Crozer  Griffith.  ■  It  is  an  acnte  infections  disease,  con- 
tagious from  person  to  person,  through  the  atmosphere,  though  not  as 
highly  so  as  measles.  It  may  occur  in  the  same  person  a  number  of 
times,  and  may  attack  those  who  have  had  measles.  All  children 
exposed  do  not  develop  the  disease. 

Age. — The  youngest  patient  in  the  author's  experience  was  seven 
weeks  old.  The  affection  may  occur  at  any  age.  The  author  has 
seen  cases  in  adults.     It  occurs  with  the  same  frequency  in  both  sexes. 

Prodromal  Period. — There  is  a  prodromal  period,  during  which 
there  may  be  a  slight  suffusion  of  the  eyes,  with  swelling  of  the  con- 
junctival fold  at  the  inner  canthus  of  the  eye.  In  two  cases  observed 
by  the  author  the  lymph-nodes  behind  the  border  of  the  sternomastoid 
muscle  were  enlarged  six  days  before  the  appearance  of  the  exan- 
thema. There  is  no  fever  or  constitutional  disturbance.  The  period 
of  incubation  is  placed  by  Thomas  and  Emminghaus  at  from  fifteen 
to  twenty  days.  Just  prior  to  the  eruption  there  are  headache,  nausea, 
and  bronchial  irritation  (Forcheimer,  Emminghaus). 

Symptoms. — Exanthema-. — The  exanthema  resembles  that  of  mea- 
sles so  closely  that  at  the  outset  it  is  common  for  physicians  to  mis- 
take one  for  the  other.  It  is  also  similar  in  that  it  is  first  noticed  to 
appear  faintly  around  the  alas  nasi  and  on  the  upper  lips.  The  exan- 
thema appears  first  on  the  face,  at  the  temporal  regions,  and  on  the 
cheeks.  It  is  in  some  cases  preceded  by  an  erythematous  blush  dif- 
fused over  the  whole  face  (Emminghaus),  which  disappears  in  a  few 
hours,  leaving  the  true  exanthema  (pre-exanthematic  erythema). 
The  exanthema  is  papular,  of  a  deep  rose-red  color,  and  distinctly 
arranged  in  crescentic  outlines.  This  arrangement  of  the  papules  in 
circles  and  half  circles  can  be  made  out  where  the  eruption  is  spread- 
ing. On  the  face  and  neck  it  gives  place  to  the  blotchy  appearance 
characteristic  of  measles.  As  a  rule,  the  eruption  remains  discrete. 
(Edema  of  the  skin  is  rarely  present. 

The  papules  have  been  described  as  of  two  varieties — one  the  size 
of  those  in  measles,  and  the  other  punctate  (Thomas).  The  punctate 
papules  have  been  seen  by  the  author  on  the  upper  part  of  the  chest, 
where  the  eruption  is  confluent.  They  are  likely  to  be  mistaken  in 
these  cases  for  the  exanthema  of  scarlet  fever.  In  some  cases  of 
Thomas  and  of  the  author  the  punctate  papules  only  were  present 
over  the  whole  trunk.  There  is  an  absence  of  the  intense  dermatitis 
seen  in  scarlet  fever,  and  the  individual  roseolar  spots  have  the  out- 
line above  referred  to. 


292  THE  SPECIFIC  INFECTIOUS  DISEASES.  ,   " 

The  exanthema,  while  fading  on  the  face  and  chest,  spreads  slowly 
on  the  extremities,  remaining  discrete  where  it  is  spreading.  It 
remains  at  its  efflorescence  on  the  face  and  trunk  from  a  few  hours  to 
a  day,  when  it  begins  to  fade  first  from  the  face,  and  then  from  the 
trunk.  A  patient  may  present  a  perfectly  normal  skin  twenty-four 
hours  after  the  appearance  of  the  eruption.  Evidences  of  the  erup- 
tion may  remain  on  the  trunk  and  skin  for  two  or  three  days.  The 
skin  then  may  present  bluish  or  brownish  crescentic  spots  in  place 
of  the  original  exanthema,  similar  to  what  is  seen  in  simple  erythema. 
Four  days  after  the  eruption  has  appeared  the  skin  in  most  cases  will 
have  a  normal  hue.  There  is  no  pigmentation  or  discoloration  as 
in  measles. 

Desquamation. — Desquamation  is  not  always  apparent.  It  is 
possible  in  exceptional  cases  to  see  a  very  slight  desquamation  on  the 
upper  part  of  the  thorax  or  inner  aspect  of  the  thighs. 

The  Eruption  on  the  Mucous  Membranes. — In  rotheln  the  erup- 
tion on  the  mucous  membranes  does  not  resemble  the  exanthema  of 
the  skin.  There  is  an  eruption  in  the  mouth,  but  it  is  not  charac- 
teristic. There  is  a  mild  injection  of  the  conjunctiva,  a  redness  of 
the  fauces,  and  perhaps  a  slight  cough.  Coryza,  photophobia,  and 
bronchitis  are  absent.  The  mild  angina  and  the  injection  of  the  con- 
junctiva resemble  what  is  seen  in  la  grippe.  Thomas  and  Emming- 
haus  have  described  an  irregular,  spotted,  streaked  appearance,  with 
small  grayish  miliary  vesicles,  on  the  soft  and  the  hard  palate.  Ger- 
hardt  has  described  a  spotted  hemorrhagic  eruption  on  the  palate,  and 
Forcheimer  an  irregular  macular  rose-red  eruption  on  the  soft  palate. 
ISTone  of  these  is  constant  or  characteristic  of  rotheln,  but  all  are 
found  in  other  affections.  The  buccal  mucous  membrane,  however, 
is  absolutely  free  from  eruption  of  any  kind,  and  in  this  fact  we  have 
a  valuable  diagnostic  distinction  between  this  disease  and  measles. 
In  a  small  percentage  of  cases  a  few  red  stellate  spots  on  the  buccal 
mucous  membrane  have  been  seen  by  the  author.  In  no  case,  how- 
ever, was  the  measles  spot  with  its  bluish-white  central  speck  present. 

Temperature. — The  temperature  may  at  the  outset  be  99.8°  F. 
(37.5°  C.)  in  the  rectum,  and  continue  at  this  point  throughout  the 
disease.  It  may  be  102°  F.  (38.8°  C),  rarely  higher.  The  tem- 
perature is  highest  at  the  outset  when  the  exanthema  appears  on  the 
face  (Fig.  40).  It  falls  rapidly  within  a  few  hours  by  a  sort  of 
crisis.     Meanwhile  the  eruption  may  spread  to  the  lower  extremities. 

Lymph-nodes. — The  author  has  studied  a  number  of  cases  with 
especial  reference  to  the  lymph-nodes.  Before  the  appearance  of  the 
eruption  the  nodes  behind  the  sternomastoid  and  angles  of  the  jaw 
may  be  enlarged.  At  the  time  of  appearance  of  the  exanthema  the 
nodes  of  the  axilla,  bicipital  groove,  and  groin  become  enlarged  to  the 


EOTHELN. 


293 


size  of  a  beau  or  larger.  The  nodes  may  remain  enlarged  for  weeks 
after  the  eruption  has  disappeared. 

S'pleen, — The  spleen  is  not  enlarged. 

The  Genitals. — In  one  case  the  injection  of  the  vulvar  mucous 
membrane  caused  temporary  dysuria. 

Complications. — Kotheln  is  such  a  mild  disease  that  complications 
are  rare. 

Prognosis. — The  patients  recover  rapidly. 

Diagnosis. — The  diagnosis  of  rotheln  should  not  present  any  diffi- 
culties. It  is  most  likely  to  be  confounded  with  measles,  scarlet 
fever,  and  erythematous  eruptions. 


Fig 

40 

. 

DAY  OF 
MONTH 

1 

'- 

3 

4 

DAY 

A.M. 

P.M. 

A.M. 

P.M. 

A.M. 

P.M. 

A.M. 

101° 

X 

-100° 

> 

o 

- 

\ 

lU 

1 

UJ 

\ 

3 

/ 

< 

\ 

L- 

\ 

'-' 

^ 

O 

1 

o 

V 

^ 

^ 

1- 

99^ 

N 

u 

S 

UJ 

■^ 

— ■ 

, 

^ 

"N 

^ 

S 

k 

^ 

-^ 

PULSE 

108 

116 

120 

120 

120 

108 

104 

RESP. 

■Zi 

■i-i 

34 

'U 

30 

23 

20 

Temperature-curve  of  a  case  of  rotheln  in  a  boy  six  years  of  age. 
from  the  outset. 


Observed 


The  symptoms  are  much  milder,  and  there  is  an  absence  of  the . 
specific  buccal  enanthema  of  measles.     Measles  does  not,  as  a  rule, 
present  simultaneous  lymph-node  enlargements  all  over  the  body,  such 
as  are  seen  in  rotheln. 

Scarlet  fever  presents  a  severe  dermatitis,  which  is  absent  in 
rotheln.  There  is  a  marked  angina  of  a  progressive  type,  with  high 
temperature.  The  general  enlargement  of  lymph-nodes  is  not  so 
useful  a  sign,  since  in  scarlet  fever  the  lymph-nodes  of  the  neck  may 
be  enlarged  at  the  angle  of  the  jaw,  or  those  in  the  axillae  and  in  the 
groin  may  enlarge  as  the  eruption  develops.  In  scarlet  fever  there  is 
a  characteristic  desquamation. 

Erythematous  eruptions  of  the  small  papular  type  may  resemble 
rotheln,  but  the  characteristic  crescentic  outline  of  the  rotheln  roseola 
is  absent. 

Treatment.^ — Isolation  need  not  be  rigid.  Children  are  kept  in- 
doors in  summer  until  the  eruption  has  disappeared  and  the  tem- 


294  TEE    SPECIFIC    INFECTIOUS    DISEASES. 

perature  is  normal.  In  the  winter  months  the  patients  are  kept 
indoors  one  week  from  the  onset  of  the  disease.  The  angina  rarely 
requires  treatment. 

MEASLES. 

(Bubeola;  MorMlli.) 

Measles  is  an  acnte  infectious  disease  distinguished  hj  a  charac- 
teristic eruption  or  exanthema  on  the  skin  and  enanthema  on  the 
mucous  membrane  of  the  mouth.  It  is  highly  contagious.  The 
specific  agent  has  not  been  isolated.  Most  people  are  susceptible  to 
measles,  and  suffer  from  at  least  one  attack.  Infants  up  to  the  age 
of  five  months  are  not  as  susceptible  as  at  a  later  period.  IsTewborn 
infants  have  been  infected  by  the  mother,  and  the  foetus  has  been 
infected  in  utero.  The  foetus  in  such  cases  may  be  expelled  pre- 
maturely, and  at  birth  is  found  covered  with  the  exanthema;  or,  if 
the  infection  occurs  at  full  term,  the  foetus  may  be  expelled  alive 
covered  with  the  exanthema  (Squire).  The  firstborn  only  is  believed 
by  Thomas  to  be  immune  for  the  period  mentioned.  The  disease  is 
very  infrequent  during  the  first  year  of  life.  Bartels  calculates  the 
occurrence  at  this  time  at  5  per  cent,  of  the  total  number  of  cases. 
The  author  has  seen  measles  in  infants  under  five  months  of  age. 
Measles  is  most  frequent  between  the  age  of  one  and  five  years  (Bartels, 
Henoch).  It  is  prevalent  in  all  countries  of  the  globe;  climate  or 
meteorological  conditions  seem  to  have  no  influence  upon  its  preva- 
lence either  endemically  or  epidemically. 

Measles  has  a  well-defined  period  of  incubation,  varying  from 
thirteen  to  fifteen  days  (Van  Panum).  In  calculating  this  period 
we  include  the  time  which  elapses  from  exposure  to  the  appearance 
of  the  eruption  on  the  body.  It  will  be  seen  later  that  this  period 
includes  the  period  of  incubation  proper,  in  which  absolutely  no 
symptoms,  not  even  fever  or  malaise,  are  apparent,  and  the  period 
of  the  enanthema  on  the  mucous  membrane.  The  enanthema,  which 
may  be  accompanied  by  coryza  of  mild  or  severe  type,  may  appear 
from  the  ninth  to  the  tenth  day  after  exposure,  and  lasts  from  three 
to  five  days.  Thus  while  the  coryza  may  be  postponed  several  days 
or  the  enanthema  may  be  present  for  a  variable  period,  the  two  periods 
together  have  a  duration  of  from  thirteen  to  fifteen  days.  I  have 
seen  the  enanthema  fully  five  days  before  the  exanthema,  and  have 
seen  cases  of  this  kind  without  any  manifestations  of  coryza  to  sig- 
nalize the  onset  of  the  disease.  It  is  erroneous,  therefore,  to  calculate 
the  period  of  incubation  from  the  exposure  to  the  onset  of  coryza,  as 
the  latter  is  variable  as  to  the  time  of  its  appearance. 

One  attack  protects  the  individual  from  subsequent  attacks.     Au- 


MEASLES.  295 

thentic  cases  of  two  attacks  in  the  same  individual  have  recently 
been  recorded.  By  this  is  not  meant  a  recrudescence  of  the  exan- 
thema after  it  has  once  faded.  This  is  also  knov^m  to  occur  ( Jlirgen- 
sen).  Experiments  have  proved  that  measles  is  highly  contagious 
in  the  catarrhal  stage.  Inoculations  with  the  blood  (Home)  and 
nasal  secretions  (Mayr)  have  given  positive  results.  The  period  of 
greatest  contagion  extends  through  the  period  of  the  exanthema.  It 
diminishes  as  the  exanthema  fades,  and  is  thought  to  disappear  grad- 
ually during  the  period  of  desquamation.  Thus  though  more  general 
in  its  power  to  infect,  the  poison  of  measles  has  a  shorter  period  of 
life  than  that  of  scarlet  fever.  The  poison  of  the  latter  disease  may 
retain  its  power  of  infection  months  after  the  disease  has  run  its 
course.  From  what  has  been  said,  it  will  be  understood  that  the 
infection  of  measles  takes  place  in  the  vast  majority  of  cases  in  the 
stage  of  the  enanthema  (incubation).  At  this  time  there  may  be 
no  coryza. 

Infection  occurs  during  the  stage  of  desquamation  (Baginsky). 
If  ordinary  caution  is  exercised,  it  is  doubtful  whether  measles  is 
ever  carried  by  a  healthy  individual  to  a  third  person  as  scarlet  fever 
is.  Baginsky  records  an  epidemic  caused  in  this  manner.  The 
poison  does  not  adhere  to  articles  of  furniture  and  wearing  apparel 
with  the  same  tenacity  as  that  of  scarlet  fever. 

Symptoms. — The  ordinary  simple  type  of  measles  is  that  which 
runs  its  course  without  any  complications  or  sequelae.  There  is  a 
prodromal  period,  which  includes  the  period  of  incubation  before  the 
appearance  of  the  enanthema  on  the  mucous  membrane  of  the  mouth. 
During  this  period  it  is  well  established  that  there  are  no  clinical 
symptoms  whatever — neither  fever  nor  malaise.  At  the  time  of  the 
appearance  of  the  enanthema  on  the  mucous  membrane  the  patient 
begins  to  feel  slightly  ill.  The  symptoms  may  be  only  a  headache  or 
a  slight  disturbance  of  the  stomach.  The  author  had  noted  in  some 
cases  a  rise  of  a  degree  or  more  in  temperature  toward  evening. 
There  are  at  this  time  slight  injection  of  the  eyes  and  general  lassi- 
tude. Coryza  is  not  pronounced.  The  patient  during  the  first  days 
of  the  enanthema,  and  by  this  is  meant  forty-eight  to  seventy-two 
hours  before  the  appearance  of  the  exanthema  on  the  skin,  presents 
few  signs  of  illness. 

If,  guided  by  the  very  faint  redness  at  the  inner  canthus  of  the 
eyes,  we  look  into  the  mouth,  a  few  spots  of  a  very  characteristic 
eruption  are  seen  on  the  buccal  mucous  membrane.  This  eruption 
is  pathognomonic  of  the  invasion  of  measles,  and  will  be  later  de- 
scribed as  the  enanthema.  After  forty-eight  to  seventy-two  hours, 
and  in  some  cases  a  longer  period,  there  are  coryza,  cough,  and  con- 
junctivitis. There  is  a  slight  febrile  movement,  varying  in  intensity 
in  different  cases. 


296  THE  SPECIFIC  INFECTIOUS  DISEASES. 

The  exanthema  now  appears,  and  is  first  noticed  at  the  temporal 
region  of  the  face  and  the  alfe  nasi  as  a  macular  rose-red  spotted  erup- 
tion, which  becomes  papular  later  in  the  course  of  the  disease.  The 
face  and  scalp  are  now  fully  covered  by  the  rose-red  irregularly  shaped 
papules,  which  next  appear  in  rapid  succession  on  the  back  of  the 
hands,  forearms,  anterior  part  of  the  trunk,  back,  and  lower  extremi- 
ties. This  order  of  the  appearance  of  the  exanthema  is  not  always 
maintained.  In  some  cases,  as  pointed  out  by  Rehn,  and  verified  by 
the  author,  the  eruption  may  first  appear  on  the  back.  It  is,  there- 
fore, advisable  to  examine  the  patient  in  a  nude  state. 

The  eruptive  stage  of  measles  generally  lasts  three  or  four  days, 
during  which  the  patient  has  an  exacerbation  of  all  the  sym^jtoms  of 
the  stage  of  invasion.  There  are  intense  photophobia,  active  coryza, 
and  a  croupy  cough  as  a  result  of  the  invasion  of  the  laryngeal  mucous 
membrane  by  the  enanthema.  The  bronchi  are  also  affected,  and 
there  are  symptoms  of  acute  bronchitis.  Even  very  mild  cases  of 
measles  show  laryngeal  and  bronchial  involvement.  At  this  stage 
the  exanthema  on  the  skin  is  general  and  profuse,  and  in  places  con- 
fluent. The  patches  of  healthy  skin  are  crescentic,  owing  to  the  pecu- 
liar conformation  of  the  papules.  In  some  mild  cases  the  rash  may 
be  very  diffuse,  but  in  others  discrete.  In  the  mildest  forms  of 
measles  the  rash  closely  resembles  in  the  latter  respect  that  seen  in 
rotheln. 

The  fever  reaches  its  height  when  the  eruption  on  the  skin  is  fully 
developed.  If  the  mucous  membrane  is  inspected  at  the  height  of 
the  skin  eruption,  it  will  be  seen  that  the  enanthema  becomes  diifuse 
before  the  eruption  of  the  skin  is  fully  developed.  The  mucous  mem- 
brane of  the  mouth  is  diffusely  inflamed  and  studded  with  bluish- 
white  specks  which  rapidly  disappear  or  desquamate.  The  eruption 
on  the  skin  persists  for  three  or  four  days  and  then  begins  to  fade. 
With  disappearance  of  the  eruption  the  general  symptoms  abate. 
The  fever  remits,  and  the  temperature  becomes  normal  by  gradual 
morning  remissions.  The  coryza,  cough,  and  photophobia  lessen,  and 
the  patient  passes  into  the  convalescent  period.  Desquamation  begins 
when  the  pinkish  hue  of  the  eruption  has  disappeared.  This  stage 
continues  until  the  last  vestige  of  pigmented  spots  on  the  skin  has 
disappeared.  As  a  rule,  it  is  completed  two  weeks  after  the  exan- 
thema has  made  its  appearance.  Desquamation  is  never  absent  in 
measles  (Crozer  Griflith),  but  it  may  be  difficult  to  detect  its  pres- 
ence. The  epithelium  is  shed  in  the  formof  branny  scales.  Desqua- 
mation is  best  seen  on  the  anterior  part  of  the  chest,  shoulders,  and 
inner  surface  of  the  thighs.  In  uncomplicated  cases  it  is  not  attended 
by  constitutional  symptoms. 

The   Temperature.  —  Measles   presents   no    characteristic   fever- 


MEASLES. 


297 


curve.  The  invasion  is  rarely  signalized  by  a  chill.  There  may  be 
a  slight  sensation  of  chilliness.  The  prodromal  period  before  the 
appearance  of  the  enanthema  is  not  marked  by  fever.  The  period 
of  the  enanthema  presents  a  slight  temperature  with  morning  remis- 
sions to  normal  (Fig.  36).  When  the  eruption  appears  on  the  skin 
the  fever  increases,  and  reaches  its  height  after  thirty-six  hours,  at 
the  time  of  the  full  development  of  the  eruption.  The  temperature 
continues  high  v^^ith  morning  or  evening  remissions  for  from  one  and 
a  half  to  tw^o  and  a  half  days,  and  then  subsides,  and  disappears  in 
from  twenty-four  to  thirty-six  hours  after  desquamation  has  set  in. 
The  temperature  may  reach  104:°-105.8°  F.  (40°-41°  C.)  without 
complications.  During  the  stage  of  desquamation  the  temperature 
is  not  elevated  unless  complication  exists  in  the  lung  or  elsewhere 
(Fig.  41). 

Fig.  41. 


S5nt°; 

1 

2 

3 

4 

6 

6 

=          1 

HOUR 

3 

li 

9 

12 

■' 

ti 

9 

12 

3 

6 

9 

12 

3 

6 

9 

12 

3 

6 

9 

12 

3 

6 

9|12 

3 

6 

9 

12 

3 

09 

12 

3 

6 

9 

12 

3 

" 

9 

12 

3 

6 

9 

12 

3 

6 

9 

12 

u 

9 

12 

' 

0 

» 

12 

lOi 

103 
i  102 

i- 
lUO 

99° 

10 

N- 

\T 

H 

:ic 

- 

s 

/ 

\ 

f 

1 

s 

/ 

s 

\ 

r 

s 

^ 

V 

s 

PULSE 

"O/llO 

n^ 

^120 

.0, 

''iso 

no. 

Iso 

11 

0 

110^ 

^115 

90^ 

io       1 

Uncomplicated  measles  in  a  boy  of  five  years. 


I  have  sketched  the  type  of  disease  which  is  not  complicated  by 
serious  affection  of  the  viscera  and  which  has  no  sequelae.  On 
account  of  variations  from  the  simple  type  just  described,  measles 
is  one  of  the  most  dreaded  diseases  of  infancy  and  childhood. 

In  fatal  cases  occurring  during  the  first  two  years  of  life  the  lung 
is  generally  involved  (Henoch).  The  appearance  of  the  eruption  is 
ushered  in  with  a  convulsive  seizure  or  a  chill.  The  pneumonia 
appears  as  the  eruption  reaches  its  height,  and  within  two  weeks 
either  proves  fatal  or  else  leaves  the  patient  weakened  or  the  subject 
of  an  empyema.  The  infection  of  the  kidneys  may  be  so  severe  as 
to  prove  speedily  fatal,  or  there  may  be  severe  mastoid  disease.  On 
the  other  hand,  there  are  cases  of  measles  of  a  type  so  mild  as  to 
cause  little  constitutional  disturbance.  The  fever  is  very  mild  and 
evanescent,  and  present  only  at  the  outbreak  of  the  eruption,  and 


298  IRE  SPECIFIC  IXFECIIOrS  DISEASES. 

even  at  this  stage  may  be  so  slight  as  to  escape  notice.     Jiirgensen 
records  measles  without  fever. 

The  Enanthema, — This  is  the  eruption  which  appears  on  the 
mucous  membrane  of  the  mouth.  It  differs  from  the  exanthema  in 
respect  to  location.  The  enanthema  appears  in  the  mouth  from  three 
to  five  days  before  the  appearance  of  the  exanthema.  It  is  accom- 
panied by  redness  of  the  pharynx,  and  of  the  anterior  and  posterior 
pillars  of  the  fauces.  The  soft  palate  is  studded  with  irregularly 
shaped  rose-colored  spots  or  streaks.  The  spots  on  the  hard  palate 
present  small  whitish,  punctate,  miliary  vesicles.  These  spots  are 
also  found  on  the  otherwise  normally  colored  mucous  membrane  of 
the  cheeks  and  on  that  opposite  the  gTims  of  the  upper  and  lower 
molar  teeth.  They  have  been  described  by  Flindt  in  these  localities 
and  on  the  palpebral  conjunctiva.  Filatow  has  described  a  desqua- 
mation of  the  epithelium  of  the  mucous  membrane  of  the  lips  and 
cheeks,  in  the  form  of  minute  whitish  shreds  (Slawyk).  A  complete 
series  of  studies  of  the  enanthema  of  measles  has  been  made,  and 
there  can,  therefore,  be  no  doubt  of  its  existence.  In  1896  I  pub- 
lished a  study  of  the  enanthema  on  the  buccal  mucous  membrane,  and 
on  the  inner  surface  of  the  lips.  In  this  study  I  showed  that  the 
enanthema  on  the  hard  and  soft  palate  so  frequently  described  since 
the  publication  of  Rehn  was  not  peculiar  to  measles.  The  spots  of 
rose-colored  papules  or  streaks  with  the  superimposed  miliary  vesicles 
are  found  in  rotheln,  scarlet  fever,  and  some  cases  of  simple  angina. 
The  eruption  on  the  buccal  mucous  membrane  alone,  however,  pre- 
ceding the  appearance  of  the  exanthema  on  the  skin  by  a  period  of 
from  three  to  five  days,  is  characteristic  of  the  invasion  of  measles. 
It  is  pathognomonic  of  the  disease,  and  occurs  in  no  other  known  con- 
ditions. It  is  almost  invariably  present,  observations  having  shown 
it  to  be  absent  in  only  a  very  small  percentage  of  cases  (Plate  XIV.). 

On  looking  at  the  mucous  membrane  lining  the  cheeks  (buccal) 
in  strong  sunlight,  a  very  characteristic  eruption  of  irregular  stellate 
or  round  rose-colored  spots  is  seen.  In  the  centre  of  each  spot  there 
is  a  bluish-white  speck.  This  appearance  of  a  bluish-white  speck  on 
a  rose-colored  background  is  pathognomonic  of  the  onset  of  measles. 
The  speck  is  sometimes  so  minute  that  strong  sunlight  is  necessary 
to  render  it  visible.  The  number  of  specks  at  the  outset  may  be  less 
than  half  a  dozen.  In  a  short  time  they  become  more  numerous,  and 
the  rose-colored  spots  become  confluent,  so  that  there  are  ditfusely  red 
patches  of  buccal  mucous  membrane  studded  with  bluish-while  specks. 
The  specks  rarely  or  never  become  confluent;  their  color  does  not 
resemble  that  of  sprue,  nor  are  they  as  coarse  as  sprue  accumulations. 
They  are  seen  on  the  inner  surface  of  the  lips,  and  are  sometimes 
well  marked  on  the  buccal  mucous  membrane  adjacent  to  the  aiims 


PLATE  XIV 


FIG.    8. 


FIG.    4. 


The  Pathognomonic  Sign  of  Measles  (Koplik's  Spots). 

Fig.   1.     The  discrete  measles  spots  on  the  buccal  mucous  membrane,  showing  the  isolated  rose-red 
spot,  with  the  minute  bluish-white  centre,  on  the  normally  colored  mucous  membrane. 

Fig.  2.     Shows  the  increased  eruption  of  spots  on  the  mucous  membrane  of  the  cheeks ;  patches  of  pale 
pink  interspersed  among  rose-red  areas,  the  latter  showing  numerous  pale  bluish-white  spots. 

Fig.  3.     The  appearance  of  the  buccal  mucous  membrane  when  the  measles  spots  coalesce  and  give  a 
diffuse  redness,  with  myriads  of  bluish-white  specks.     The  exanthema  is  at  this  time  fully  developed. 

Fig.   4.     Aphthous  stomatitis  sometimes  mistaken  for  measles  spots.      Mucous  membrane  normal  in 
color.'     Minute  ydlotv  points  are  surrounded  by  a  red  area.     Always  discrete. 


MEASLES. 


299 


of  the  upper  molar  teeth.  If  the  finger  is  passed  over  the  mucous 
membrane,  they  are  felt  to  be  raised  and  firmly  adherent.  They  can 
be  rubbed  off  by  force  or  picked  oft"  with  forceps.  As  the  exanthema 
spreads,  the  enanthema  of  the  buccal  mucous  membrane  becomes  dif- 
fuse. When  the  exanthema  is  at  its  height  and  during  efflorescence 
the  eruption  on  the  mucous  membrane  begins  to  lose  its  character- 
istics. The  bluish-white  specks  are  washed  away  by  the  buccal  secre- 
tions and  leave  the  mucous  membrane  diffusely  reddened  and  raw. 

Fig.  42. 


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Case  of  measles  observed  from  the  flrst  appearance  of  the  "  Koplik  spots  "  to  the 
time  of  the  outbreak  of  the  exanthema,  a  period  of  fully  four  days.  During  this  time 
it  appears  there  was  a  gradually  rising  curve  of  temperature  without  any  exanthema 
with  a  low  leucocyte  count. 


By  referring  to  the  temperature-curve,  it  will  be  seen  that  the 
appearance  of  the  enanthema  is  accompanied  before  the  outbreak  of 
the  skin  eruption  by  fever  of  a  low  type  (Fig-  42).  There  is  also 
at  this  time  a  leucopenia ;  a  diazo  reaction  appears  in  the  urine  at 
the  time  of  the  outbreak  of  the  exanthema. 


300  THE  SPECIFIC  INFECTIOUS  DISEASES. 

Exantliema. — The  exanthema  of  measles  is  a  characteristic  erup- 
tion of  rose-colored  or  purple-colored  papules,  varying  in  diameter 
from  1  millimetre  to  1  centimetre,  the  average  diameter  being  2  milli- 
metres. They  are  irregularly  circular,  or  longer  in  one  diameter 
than  another,  or  shaped  like  a  half -moon.  They  arrange  themselves 
crescentically.  They  are  at  first  discrete,  but  soon  become  confl^^ent, 
so  that  large  areas  of  skin  are  covered.  Here  and  there  are  areas  of 
normally  colored  skin.  The  discrete  papules  have  a  distinctly  cres- 
centic  arrangement.  This  is  seen  on  the  thorax  and  thighs.  As  a 
rule,  the  whole  face  is  covered  with  the  eruption,  and  the  skin  swollen. 
The  eruption  spreads  from  the  face  and  head  to  the  back  of  the  neck, 
throat,  upper  part  of  the  back,  chest,  and  back  of  the  hands  and  arms. 
The  lower  extremities  become  affected,  as  well  as  the  palms  of  the 
hands  and  soles  of  the  feet.  As  a  rule,  the  eruption  on  the  skin  is 
papular;  the  papules  may  show  at  their  summit  miliary  vesicles. 
They  may  become  confluent  and  form  patches.  Hemorrhages  may 
occur  in  and  around  the  papules  (Morbilli  hsemorrhagica).  In  these 
cases  petechise  occur  in  the  course  of  the  exanthema,  and  persist  into 
the  period  of  desquamation.  They  should  not  be  confounded  with 
petechial  eruptions  or  purpura,  which  may  appear  after  the  exan- 
thema has  run  its  course.  The  exanthema  in  weakly  children  may 
be  limited  in  its  distribution  and  not  characteristic.  Henoch  believes 
that  many  cases  in  which  the  exanthema  does  not  develop  in  sequence, 
take  a  subsequent  course  which  may.  be  severe.  If  therefore  the  ex- 
anthema should  first  appear  on  the  back,  instead  of  the  face,  and 
spread  thence,  complications  may  be  expected.  Although  complica- 
tions occur  with  eruptions  which  are  diffuse  and  very  general,  the 
severity  of  the  eruption  is  no  index  as  to  the  severity  of  the  disease. 

When  the  exanthema  fades,  it  leaves  the  skin  studded  with  dirty 
brownish-colored  spots,  which  have  the  arrangement  of  the  original 
exanthema.  These  pigmented  areas  gradually  fade,  and  when  des- 
quamation is  complete  they  disappear. 

Measles  may  run  its  course  without  the  appearance  of  the  exan- 
thema on  the  face.  It  may  be  ill-defined  and  limited  to  certain  parts 
of  the  body.  It  may  develop  in  full  intensity  and  then  suddenly  fade 
within  a  few  hours.  This  occurs  in  cases  in  which  severe  disturb- 
ances of  the  circulation  alter  the  distribution  of  blood  in  the  skin. 
In  these  cases  there  may  be  a  complication  of  the  lungs  or  heart,  but 
the  fading  of  the  exanthema  is  not,  as  is  thought  by  the  laity,  pri- 
marily the  cause  of  any  affection  of  the  internal  organs. 

Complications. — The  Nose,  Pharynx,  and  Larynx. — In  very  young 
infants  severe  inflammation  of  the  mucous  membrane  of  the  nose  and 
nasopharynx  may  lead  to  difficulties  not  only  in  breathing,  but  also 
in  feeding.     In  these  cases  membrane  rarely  develops.     If  it  does 


MEASLES.  301 

appear,  it  takes  the  form  of  a  pseudomembranous  rhinitis,  generally 
of  a  diphtheroid  streptococcic  nature.  Its  course  then  may  be  sub- 
acute. The  larynx  is  sometimes  severely  affected,  so  that  at  the 
height  of  the  exanthema  the  patient  is  troubled  with  a  harassing, 
croupy  cough.  In  some  cases  the  patient  becomes  almost  aphonic. 
If  there  is  no  obstruction  to  the  breathing,  this  symptom,  which  causes 
great  concern,  disappears.  The  larynx  may  present  a  pseudomem- 
branous affection  of  a  streptococcic  nature.  Gerhardt  has  shown  that 
ulceration  of  the  posterior  laryngeal  wall  may  ensue  from  traumatism 
to  the  larynx  as  a  result  of  repeated  fits  of  coughing.  If  these  ulcera- 
tions cause  swelling  of  the  mucous  membrane,  obstruction  to  respira- 
tion may  result.  The  bronchitis  which  is  always  present  in  such 
cases  may  cause  obstruction  of  the  finer  bronchi.  On  account  of  inef- 
ficient respiratory  effort  atelectasis  and  pneumonia  may  result,  with 
fatal  issue. 

Diphtheria. — Diphtheria  may  complicate  measles.  It  may  pre- 
cede the  eruption,  or  may  develop  at  any  time  during  the  attack.  In 
all  such  cases  the  patient  has  been  exposed  to  a  diphtheritic  infection. 
A  case  in  the  author's  hospital  service  had  recovered  from  diphtheria 
two  weeks  previous  to  the  attack  of  measles.  Three  days  after  the 
appearance  of  the  exanthema  the  conjunctiva  became  covered  with 
true  diphtheritic  membrane.  The  larynx  then  became  involved,  and 
stenosis  set  in  within  twenty-four  hours  after  the  appearance  of  the 
membrane  on  the  conjunctiva.  The  exanthema  in  these  cases  is  likely 
to  fade  rapidly  or  become  hemorrhagic.  Diphtheria  complicated  with 
measles  is  rapidly  fatal,  since  the  trachea  and  bronchi  become  involved. 
Fatal  pneumonia  supervenes.  On  the  other  hand,  the  author  has 
seen  a  croupy  cough  with  dyspnoea,  set  in  three  weeks  after  convales- 
cence from  measles.  Diphtheria  bacilli  were  found  in  the  pharynx.  In 
this  case  no  pseudomembrane  on  the  pharynx  was  visible.  It  is  not 
always  possible  to  decide  in  a  given  case  whether  there  is  a  simple 
swelling  of  the  mucous  membrane  of  the  larynx  or  a  pseudomem- 
branous process.  In  cases  with  severe  laryngeal  symptoms,  if  no 
membrane  is  visible,  a  culture  of  the  secretions  of  the  pharynx  should 
be  made.  The  temperature-curve  does  not  aid  us.  Diphtheria  may 
run  its  course  with  a  low  or  a  high  temperature.  The  pulse  is  of 
little  assistance  in  making  a  diagnosis.  There  is  nothing  in  the 
nature  of  measles  which  predisposes  toward  diphtheritic  infection. 

During  convalescence  persistent  hoarseness  or  aphonia  is  not  infre- 
quently seen  without  other  disturbances.  The  voice  gradually  returns 
to  the  normal. 

Prudden  and  ISTorthrup,  in  a  paper  on  diphtheria  with  fatal 
pneumonia,  record  three  cases  of  fatal  diphtheria  complicating  mea- 
sles.    The  diphtheria  and  subsequent  pneumonia  were  of  the  strepto- 


302  THE  SPECIFIC  IXFECTIOUS  DISEASES. 

COCCUS  variety.  The  three  cases  formed  part  of  a  series  of  seventeen 
cases  of  streptococcus  diphtheria  followed  by  pneumonia. 

Bronchitis;  Bronchopneumonia;  Atelectasis. — A  very  serious 
complication  of  measles  is  bronchitis,  which  may  involve  the  capillary 
bronchi,  causing  atelectasis  and  bronchopneumonia.  In  the  stage  of 
efflorescence  the  bronchitis  at  times  becomes  severe.  There  are  found 
on  auscultation  fine  crepitant  rales  in  addition  to  the  very  coarse 
mucous  and  sonorous  rales.  At  the  end  of  inspiration  a  fine  crepi- 
tation is  heard,  similar  to  that  present  at  the  beginning  of  pneu- 
monia. There  is  also  subcrepitation  at  the  close  of  expiration.  In 
these  cases  the  constitutional  symptoms  are  severe,  if  large  areas  of 
lung  are  involved.  The  dyspnoea  is  extreme.  Although  cyanosis 
may  be  present,  no  areas  of  consolidation  are  detected  on  physical 
examination.  It  is  reasonable  to  infer  that  in  all  cases  of  severe 
inflammation  of  the  smaller  bronchi,  areas  of  bronchopneumonia 
exist.  Auscultation  may  reveal  areas  of  lung  in  which  the  air  enters 
imperfectly.  An  attack  of  coughing  will  open  up  the  bronchi,  when 
air  again  enters  these  areas  (atelectasis).  In  young  infants  and 
children  this  form  of  bronchitis  is  a  serious  complication.  As  a  rule, 
it  leads  to  bronchopneumonia. 

The  pneumonia  which  complicates  measles,  either  in  the  eruptive 
stage  or  in  the  desquamative  period,  is  anatomically  usually  of  the 
bronchopneumonic  type,  although  the  lobar  form  may  occur.  The 
pneumonia  is  caused  by  an  invasion  of  the  lung  tissue  by  streptococci 
from  the  bronchi.  A  bronchopneumonia  may  at  first  be  difficult  of 
detection.  As  a  rule,  however,  it  involves  a  lobe  of  the  lung  in  a 
short  time.  The  lower  portions  of  the  lung  behind  are  usually  first 
involved,  although  the  upper  lobes  or  middle  lobe  may  in  exceptional 
cases  be  first  involved.  When  consolidation  takes  place,  the  area  of 
lung  involved  may  be  as  extensive  as  in  lobar  pneumonia.  A  pneu- 
monic process  should  be  suspected  if  the  temperature  in  the  stage  of 
desquamation  does  not  fall  to  the  normal.  There  is  a  distinct  rise 
of  temperature  which  varies  in  intensity,  and  remits  in  the  morning 
to  become  higher  in  the  evening.  The  cough  becomes  troublesome, 
and  there  is  also  dyspnoea.  In  such  cases  the  temperature  alone  can- 
not be  relied  upon  for  a  diagnosis.  A  careful  physical  examination 
will  be  of  assistance.  Under  two  years  of  age  this  form  of  broncho- 
pneumonia is  very  fatal.  As  a  rule,  pneumonia  complicating  measles 
terminates,  if  not  in  immediate  recovery,  in  a  bronchopneumonia 
which  persists  for  weeks.  The  temperature  may  fall  almost  to  the 
normal  in  the  morning  and  in  the  evening  rise  a  degree  or  more.  In 
addition  to  the  bronchopneumonia  there  may  be  pleurisy,  with  thick- 
ening of  the  pleura  and  purulent  exudate.  In  some  cases  the  upper 
lobe  of  the  lung  shows  signs  of  unresolved  pneumonia  for  weeks. 


MEASLES. 


ao^ 


Emaciation  is  progressive.  All  of  these  cases  are  not  necessarily 
tuberculous.  A  tuberculous  process  may  be  engrafted  on  a  non- 
tuberculous  bronchopneumonia  at  any  time  by  infection  with  tubercle 
bacilli.  In  measles  there  seems  to  be  a  predisposition  to  invasion  of 
the  lung  by  tubercle  bacilli  through  the  catarrhal  and  inflamed  mucous 
membrane  of  the  bronchi.  We  can  reasonably  hope  for  recovery  in 
many  of  these  cases  of  simple  chronic  bronchopneumonia.  If  tuber- 
culous glands,  vi^hich  have  been  dormant  before  the  invasion  of 
measles  exist,  they  form  focal  points  for  the  development  of  tuber- 
culosis of  the  lungs  or  meninges.  Such  cases  are  fatal.  Autopsy 
will  reveal  recent  lesions  alongside  of  old  tuberculous  foci. 

The  frequency  of  infection  with  tuberculosis  varies  in  different 
localities.  In  some  epidemics  it  occurs  in  5  per  cent,  of  the  cases; 
in  others,  16  per  cent,  or  more  are  affected  (Bartels,  Jiirgensen). 

Fig.  43. 


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Measles  complicated  with  endocarditis  in  a  boy  six  years  of  age. 


The  Heart. — The  endocardium  is  rarely  affected  in  measles.  If 
endocarditis  does  occur,  it  is  usually  an  intercurrent  affection  in  a 
rheumatic  subject.  Fig.  43  shows  a  temperature-curve  from  a  case 
in  which  rheumatism  preceded  an  attack  of  measles,  and  which  in 
turn  was  followed  by  endocarditis.  Myocarditis  may  be  found  in 
fatal  cases  of  bronchopneumonia.  In  bronchopneumonia  complicated 
with  pleurisy,  pericarditis  may  also  be  present  (Baginsky). 

The  Intestines. — In  some  epidemics  diarrhoea  is  a  frequent  com- 
plication. The  movements  are  numerous,  and  watery  in  character. 
When  the  large  intestine  is  involved  the  stools  contain  blood  and 
mucus,  and  tenesmus  is  present.  The  season  of  the  year  influences 
the  intensity  of  the  infection.  In  the  warm  months  the  diarrhoea 
may  be  of  a  severe  type.  In  cases  recorded  by  Henoch  and  Thomas, 
autopsy  showed  enlarged  Peyer's  patches  and  solitary  follicles  resem- 
bling those  seen  in  typhoid  fever.  'No  cases  of  ulceration  have  been 
recorded.     Jiirgensen  is  inclined  to  regard  the  diarrhoea   a  result 


304  THE  SPECIFIC  IISFECTIOUS  DISEASES. 

of  infection  of  the  intestinal  mucons  membrane.  The  enanthema 
appears  in  this  locality  early  in  the  disease. 

The  Kidneys. — In  many  cases  of  measles,  albnmin  and  a  few 
hyaline  and  epithelial  casts  are  present  in  the  urine.  They  are  the 
result  of  a  parenchymatous  inflammation  of  the  kidney,  due  to  the 
poison  of  the  disease,  A  severe  nephritis,  such  as  is  common  in 
scarlet  fever,  is  rarely  seen.  I^ephritis  is  apt  to  occur  in  the  severe 
cases  complicated  with  bronchopneumonia.  There  may  then  be 
marked  albuminuria,  blood,  and  casts  of  all  kinds  in  the  urine,  with 
suppression.  On  the  other  hand,  nephritis  in  the  stage  of  desqua- 
mation is  uncommon.  There  is  always  in  such  cases  suspicion  that 
an  infection  coincident  with  scarlet  fever  may  have  been  overlooked 
(Henoch).  If  diphtheria  complicates  measles,  nephritis  is  likely  to 
be  present. 

The  Bones  and  Joints. — The  author  has  seen  osteomyelitis  with 
suppuration  of  the  joints  follow  measles.  Streptococci  were  found 
in  the  pus.  In  one  case  bronchopneumonia  was  an  earlier  complica- 
tion.    These  cases  are  rare. 

Lymph-nodes. — If  the  inflammation  of  the  throat  is  severe,  the 
lymph-nodes  at  the  angle  of  the  jaw  and  underneath  the  body  of  the 
jaw  may  be  enlarged.  Rarely,  however,  is  the  adenitis  as  severe  as 
in  scarlet  fever.  The  glands  or  nodes  in  the  axillae,  bicipital  groove, 
over  the  internal  condyle  of  the  elbow-joint,  and  in  the  groin  may  be 
enlarged  to  the  same  extent  as  in  rotheln,  as  a  result  of  the  processes 
taking  place  in  the  skin.  Severe  infection  of  the  gut  may  cause 
swelling  of  the  mesenteric  lymph-nodes,  which,  if  not  tuberculous, 
will  retrograde  after  the  disease  has  run  its  course. 

The  Blood. — In  measles  as  distinguished  from  scarlet  fever  an 
examination  of  the  blood  shows  a  subnormal  number  of  leucocytes 
or  a  leucopenia.  This  condition  of  the  blood  is  found  in  the  initial 
stage  of  the  disease,  and  persists  well  into  the  period  of  the  exan- 
thema in  uncomplicated  cases,  as  is  well  shown  in  Fig.  39. 

The  Nervous  System. — It  is  rare  to  see  convulsions  usher  in  an 
attack  of  measles,  even  of  a  severe  type.  In  anomalous  forms  of  the 
disease  complicated  with  pneumonia  there  may  be  cerebral  symptoms 
similar  to  those  seen  in  the  latter  affection.  There  may  in  some  cases 
be  a  complicating  cerebrospinal  meningitis  with  purulent  exudate. 
If  tuberculosis  is  present,  the  meninges  may  be  attacked,  as  in  any 
tuberculous  infection.  French  writers  have  observed  neuritis  follow- 
ing measles. 

The  Eyes. — Following  severe  cases  of  measles,  photophobia,  spasm 
of  the  orbicularis,  inflammation  of  the  lachrymal  duct,  conjunctivitis, 
ulcerations  of  the  cornea,  and  amaurosis  may  result.  Hence,  even 
in  mild  forms  of  tlic  disease  the  eyes  should  be  frequently  inspected 
(Eversbusch). 


MEASLES.  ;^>05 

The  Genitals. — The  author  has  seen  djsuria  in  cases  in  which  the 
enanthema  affected  the  mucous  membrane  of  the  vulva  in  girls. 
Henoch  records  cases  of  gangrene  (noma)  of  the  genital  organs. 

The  Mouth. — Inasmuch  as  the  mucous  membrane  of  the  mouth 
is  the  seat  of  an  active  eruption,  stomatitis  is  likely  to  be  present, 
especially  if  through  carelessness  or  traumatism  the  mucous  mem- 
brane has  become  infected  v^ith  bacteria  from  without.  In  such  cases 
aphthae  may  result.  Children  in  unhygienic  surroundings  are  likely 
to  develop  noma  of  the  cheek  if  exposed  to  the  infection. 

Pertussis. — Pertussis  is  an  occasional  complication  of  measles. 
A.S  in  diphtheritic  infection,  there  must  have  been  exposure  to  the 
contagion  of  both  pertussis  and  measles,  since  etiologically  the  dis- 
eases have  nothing  in  common.  The  danger  in  the  coincident  occur- 
rence of  measles  and  pertussis  is  that  bronchopneumonia  is  likely  to 
develop,  and  prove  a  serious  if  not  fatal  complication. 

The  Ear. — The  external  structures  of  the  ear  may  be  affected  by 
oedema  and  swelling.  The  external  auditory  canal  may  become  the 
seat  of  painful  swelling  and  diffuse  inflammation.  Gangrene  of  the 
pinna  has  been  noted  (!N^ottingham,  Bourdillot).  The  most  common 
affection  of  the  ear  is  otitis  media  catarrhalis.  Of  33  cases  of  severe 
complicated  measles,  Tobeitz  found  otitis  of  this  variety  in  16.  The 
frequency  of  otitis  varies  with  different  epidemics.  The  otitis  makes 
its  appearance  in  the  period  between  the  seventh  and  the  twenty-sixth 
day  following  the  development  of  the  exanthema.  Of  22  fatal  cases 
of  measles,  otitis  was  found  in  19,  only  Y  of  which  presented  symp- 
toms during  life.  The  great  majority  of  cases  of  otitis  give  no  pro- 
nounced symptoms  and  end  in  resolution.  These  mild  cases  are  the 
result  of  the  action  through  the  blood  of  the  measles  poison  on  the  ear 
structures  (hematogenic).  The  severe  cases  follow  a  mixed  infec- 
tion through  the  pharynx  and  Eustachian  tube.  In  the  pus  of  acute 
or  chronic  otitis,  with  or  without  inflammation  of  the  mastoid,  the 
streptococcus,  Staphylococcus  pyogenes,  and  pyogenic  diplococci  have 
been  found.  The  general  course  of  otitis  is  not  so  severe  as  that  of 
scarlet  fever.  In  some  epidemics  the  severe  and  fatal  cases  are  more 
common  than  in  others. 

Sequelae. — Any  of  the  complications  named  above  may  pursue  a 
chronic  course.  In  this  sense  only  are  they  sequelae.  Chronic 
blepharitis,  blennorrhoea,  keratitis,  otitis,  catarrhal  inflammation  or 
ulceration  with  stenosis  of  the  larynx,  septic  retropharyngeal  abscess, 
and  chronic  bronchopneumonia  may  persist  for  weeks  or  months. 

Prognosis. — The  prognosis  in  measles  varies  with  the  virulence  of 
the  epidemic,  the  resistance  of  the  individual,  and  the  age  of  the 
patient.  The  idea  prevalent  among  the  laity,  that  measles  is  a 
comparatively  mild  affection,  is  incorrect.     In  the  cases  treated  in 

20 


306  THE  SPECIFIC  INFECTIOUS  DISEASES. 

both  dispensary  and  private  practice,  and  at  all  periods  of  infancy 
and  childhood,  the  mortality  is  8  per  cent.  (Breyer).  The  mor- 
tality is  greatest  during  the  first  year  of  life,  and  niay  vary  in 
different  epidemics  from  10  to  40  per  cent.  The  lowest  mortality 
seems  to  be  between  the  fifth  and  eighth  years — 6  per  cent.  (Bagin- 
sky).  Hospital  statistics  are  of  little  value  to  the  general  practi- 
tioner, as  the  class  of  cases  treated  in  institutions  give  a  high  mortality- 
rate.  The  mortality  in  hospitals  may  be  as  high  as  30  to  35  per  cent. 
(Henoch,  Fiirbringer). 

Diagnosis. — The  diagnosis  will  in  most  cases  present  few  difii- 
culties  if  the  physician  follows  a  fixed  routine  in  the  examination  of 
the  patient.  The  mode  of  onset,  the  coryza,  the  enanthema  of  the 
buccal  mucous  membrane,  and  the  skin  eruption  are  characteristic. 
If  the  physician  will  examine  the  inner  surface  of  the  cheeks  and  the 
buccal  mucous  membrane  in  every  seemingly  slight  indisposition  of 
children,  he  will  in  certain  cases  be  able  to  predict  an  attack  of  measles 
far  in  advance  of  the  appearance  of  the  exanthema.  In  some  cases 
the  enanthema  appears  on  the  buccal  mucous  membrane  before  coryza 
is  present.  The  inspection  of  the  buccal  mucous  membrane  thus 
becomes  important  as  a  prophylactic  measure.  Strong  sunlight  is 
essential  for  thorough  inspection.  Although  the  bluish-white  spots 
on  the  rose-red  background  may  sometimes  be  seen  by  artificial  light, 
especially  electric  light,  a  diagnosis  of  measles  should  never  be  made 
at  night.  Cases  of  influenza  closely  resemble  measles  at  the  outset. 
These  present  the  injected  conjunctivae,  cough,  and  rose-colored  spots 
on  the  soft  and  the  hard  palate  seen  in  measles.  In  la  grippe,  how- 
ever, the  buccal  mucous  membrane  is  pale  and  presents  absolutely  no 
eruption.  In  one  of  the  early  grippe  epidemics  in  ISTew  York  the 
children  showed  an  ill-defined  roseolar  eruption  on  the  surface,  but 
the  buccal  eruption  was  never  present. 

Rotheln. — Botheln  in  some  cases  resembles  mild  measles  so  closely 
that  the  author  has  often  questioned  whether  so-called  cases  of  mild 
measles  without  rise  of  temperature,  described  by  authors,  were  not 
cases  of  rotheln.  The  difficulty  in  differentiation  is  increased  if 
measles  is  prevalent  at  the  same  time.  The  absence  of  the  buccal 
eruption  is  a  crucial  test.  Schmid  has  also  laid  stress  on  this  point. 
In  some  rare  cases  of  rotheln  there  may  be  seen  an  isolated,  rose-red' 
spot  here  and  there  on  the  buccal  mucous  membrane,  but  the  bluish- 
white  speck  in  the  centre  of  these  spots  is  never  seen  as  in  measles. 

Scarlet  Fever.  —  Scarlet  fever  may  at  times  closely  resemble 
measles,  especially  in  those  forms  in  which  the  eruption  on  the  face 
is  evanescent.  In  scarlet  fever  the  buccal  mucous  membrane  has  a 
normal  hue.  The  author  has  seen  scarlet  fever  complicated  with 
measles.     In  these  cases  the  scarlet  eruption  appeared  first.     Within 


MEASLES.  307 

two  or  three  days  there  was  a  general  recrudescence  of  the  exanthema, 
with  the  appearance  all  over  the  body  of  a  roseola  (the  scarlet  rash 
had  faded  somewhat),  coryza,  and  the  buccal  eruption.  In  other 
cases  the  scarlet  fever  eruption  on  the  back  of  the  hands  and  forearms 
assumes  the  blotchy,  papular  roseolar  form  of  the  exanthema  of 
measles.  The  author  has  seen  a  case  of  this  kind  in  which  an  expert 
entertained  the  possibility  of  rotheln  or  measles.  The  buccal  enan- 
thema  was  absent.  The  subsequent  course  of  the  case  proved  the 
diagnosis  of  scarlet  fever  to  be  correct. 

Typhoidal  Roseola. — The  roseola  of  typhoid  is  sometimes  so  abun- 
dant as  to  mislead  the  physician  into  mistaking  it  for  the  eruption 
of  measles.  Measles  complicating  typhoid  at  the  end  of  the  second 
week  has  come  under  the  author's  notice.  In  this  case  the  buccal 
eruption  was  profuse. 

Drug  Eruptions. — Antitoxin  and  drug  eruptions  may  simulate 
a  measles  eruption,  but  the  buccal  mucous  membrane  never  presents 
the  enanthema. 

Syphilitic  Roseola. — The  roseola  of  syphilis  frequently  resembles 
that  of  measles  so  closely  as  to  cause  uncertainty  in  the  diagnosis. 
Here  the  conjunctivse  may  be  injected,  and  there  may  be  a  slight 
febrile  disturbance  (Sobel).  The  buccal  mucous  membrane  is  pale, 
and  shows  no  eruption  resembling  that  seen  in  measles. 

The  diag-nosis  of  measles  thus  resolves  itself  into  a  recognition 
of  the  disease  before  and  after  the  appearance  of  the  skin  eruption. 
Before  the  appearance  of  the  eruption  there  is  very  little  to  guide 
us.  Cough,  coryza,  and  fever  may  accompany  an  influenza.  In  these 
cases  the  buccal  eruption  is  of  great  diagnostic  value.  After  the 
eruption  appears,  the  question  narrows  itself  to  the  differentiation  of 
measles  from  rotheln  or  scarlet  fever,  and  the  recognition  of  the 
various  forms  of  erythema,  roseola,  drug  and  antitoxin  eruptions. 

Prophylaxis. — As  soon  as  the  physician  has  made  the  diagnosis  of 
measles  or  suspects  its  presence,  the  patient  should  be  isolated  from 
other  children  of  the  family.  Among  the  poor  it  is  sometimes  im- 
possible to  do  this.  The  members  of  the  family  not  directly  con- 
cerned in  the  care  of  the  patient  should  be  denied  admittance  to  the 
sick-room.  It  is  not  necessary  to  cover  the  door  of  the  room  with 
cloths  or  sheets  moistened  with  disinfectants.  The  physician  before 
entering  the  room  should  take  off  his  coat  and  put  on  some  convenient 
linen  gown  or  bath-robe,  so  as  to  completely  cover  his  person.  This 
robe  should  hang  outside  the  door  of  the  room,  so  as  to  be  easily  acces- 
sible. When  not  in  use,  it  should  be  hung  in  the  open  air.  If  the 
physician  wears  a  beard,  he  should  wash  it  after  leaving  the  patient, 
for  if  the  patient  coughs  in  the  physician's  face,  he  is  likely  to  carry 
the  infection  in  his  beard  to  the  next  child  visited.  Should  the 
measles  be  complicated  with  diphtheria,  extra  precaution  is  necessary. 


308  THE  SPECIFIC  INFECTIOUS  DISEASES. 

Treatment. — General. — A  typical  mild  case  of  measles  needs  little 
medicinal  treatment.  We  try  to  make  the  patient  comfortable.  The 
temperature  of  the  room  should  be  about  68°-Y0°  F.  (20°-21.1°  C), 
if  possible.  The  ventilation  should  be  constant  and  attained  by 
moans  of  opening  doors  and  windows  of  rooms  communicating  with 
the  sick-room.  It  is  not  necessary  to  darken  the  room  very  much; 
in  fact,  Bartels  has  shown  that  light  and  air  are  necessary  to  the 
comfort  and  well-being  of  the  patient.  The  author  has  found  that 
the  ordinary  yellow  window-shade,  if  drawn  over  the  windows,  suffi- 
ciently excludes  the  actinic  rays  which  are  irritating  to  the  eyes. 

In  a  typical  case  of  measles  a  temperature  of  104°— 104.5°  F. 
(40°  C.)  may  be  ignored.  It  should  be  remembered  that  the  fever 
continues  only  during  the  period  of  the  eruption.  With  the  fading 
of  the  exanthema  the  temperature  becomes  normal.  It  is  only  in 
cases  in  which  there  is  a  high  temperature  with  delirium  that  medi- 
cation is  called  for.  It  is  not  uncommon  to  see  children  covered  with 
an  eruption  and  with  a  temperature  of  104°  F.  (40°  C.)  playing  in 
bed  with  their  toys. 

The  cough  will  sometimes  need  treatment.  In  such  cases  I  am 
accustomed  to  prescribe  TIX  iv  (0.25)  of  paregoric  combined  with  TTX  ij 
(0.12)  of  syrup  of  ipecacuanha,  every  three  hours.  If  the  patient  is 
kept  awake  by  the  cough,  a  small  dose  of  Dover's  powder  (grains  j 
or  ij)  (0.06  or  0.12)  or  codeine  (grain  tV  to  4)  (0.006  to  0.008)  at 
night  will  be  sufficient.  If  the  patient  is  very  restless  at  night  and 
we  do  not  wish  to  give  opiates,  grains  v  (0.3)  of  trional  will  quiet  a 
child  of  five  years.  Some  young  children  can  be  put  to  sleep  by  a 
small  dose  of  phenacetin  (grainsij)  (0.1).  In  a  mild  case,  especially 
if  there  is  pruritus  or  irritation  of  the  skin,  there  is  no  objection  to 
sponging  the  patient  once  a  day  with  water  at  100°  F.  (37.7°  C), 
containing  some  alcohol  or  a  pinch  of  sodium  bicarbonate. 

The  food  should  be  light.  Milk,  broths,  and,  when  the  fever  has 
defervesced,  chicken,  soft-boiled  eggs,  jelly,  toasted  bread,  crackers, 
rusk  {Zwiehack),  and  cereals  in  attractive  form,  with  cocoa,  comprise 
the  diet  list.  Orange-juice  or  weak  lemonade  may  be  given  in  mod- 
eration.    Water-ices  may  be  given,  if  desired. 

As  soon  as  desquamation  has  set  in,  I  direct  the  body  to  be 
anointed  every  second  day  with  an  ointment  of  washed  benzoinated 
lard  combined  with  5  per  cent,  of  boric  acid.  The  patient  is  allowed 
to  get  out  of  bed  as  soon  as  the  temperature  has  fallen  to  normal,  and 
is  permitted  to  go  out  of  doors  three  weeks  after  the  outbreak  of  the 
eruption  in  the  summer  and  four  weeks  in  the  winter  months.  Be- 
fore mingling  with  other  children,  the  patient  should  be  thoroughly 
washed  with  soap.      It  i  s  not  necessary  to  put  an  antiseptic  in  the  bath. 

The  Treatment  of  Complications. — Bronchitis;  Bronchopneumonia. 


MEASLES.  309 

■ — ^A  severe  inflammation  of  the  finer  bronchi  is  likely  to  cause  as 
much  fever,  dyspnoea,  cough,  and  restlessness  as  a  primary  broncho- 
pneumonia. The  temperature  then  rises  and  continues  elevated — 
104°,  even  105°  F.  (40°-40.5°  C.) — with  morning  remissions.  In 
these  cases  the  temperature  must  be  reduced,  I  never  hesitate  to 
utilize  hydriatic  measures.  The  most  convenient  mode  of  applying 
water  is  by  means  of  compresses  moistened  with  water  at  80°  F. 
(26.5°  C).  If  the  patient  reacts  well,  the  compresses  may  be 
applied  at  67°  F,  (19.4°  C.) ;  if  he  becomes  cold  and  cyanosed,  at 
105°  F.  (40°  C).  These  warm  compresses  are  at  times  very  sooth- 
ing, causing  the  patient  to  drop  into  a  quiet  sleep.  It  should  be 
remembered  that  the  object  of  applying  the  compresses  is  not  always 
to  reduce  temperature  rapidly,  but  rather  to  stimulate  the  heart  and 
support  the  patient.  Douching  the  head  with  ice-cold  water,  as  rec- 
ommended by  some,  is  a  very  questionable  practice.  The  use  of  the 
coal-tar  antipyretics  should  be  avoided.  In  lowering  the  temperature 
they  act  as  depressants.  In  severe  cases  of  bronchopneumonia  aconite 
should  not  be  used  to  lessen  the  rapidity  of  the  pulse.  Caffeine,  cam- 
phor, strychnine,  and  digitalis  in  proper  doses  are  more  satisfactory. 
If  a  bronchopneumonia  be  prolonged  into  the  convalescent  stage,  we 
should  be  on  the  alert  for  pleuritic  eifusion.  This  is  especially  likely 
to  occur  if  the  pneumonia  lasts  longer  than  two  weeks.  In  these  cases 
the  symptoms  present  are  similar  to  those  described  under  Pleurisy, 
and  the  treatment  is  carried  out  on  the  same  principles. 

Laryngeal  8ympioms. — The  laryngeal  symptoms  become  harass- 
ing when  there  is  much  swelling  or  slight  erosions  of  the  laryngeal 
mucous  membrane.  In  such  cases  an  improvised  tent  should  be 
erected  over  the  crib  or  bed  and  filled  with  steam  vapor  saturated  with 
thymol  or  turpentine.  Older  children  can  be  persuaded  to  breathe 
the  vapor  generated  in  an  open  kettle.  If  symptoms  of  stenosis 
appear,  it  must  at  once  be  determined  by  culture  whether  a  diph- 
theritic process,  a  streptococcic  pseudomembranous  formation,  or  a 
stenosis  due  to  simple  catarrhal  oedema  of  the  mucous  membrane  is 
present. 

Diphtheria.- — Antitoxin  is  indicated  in  diphtheria  either  of  the 
conjunctiva,  pharynx,  or  larynx.  A  large  dose  should  be  given  at 
the  outset,  on  account  of  the  virulent  nature  of  this  affection  as  a 
complication  of  measles.  We  should  not  be  too  ready  to  intubate 
on  the  first  appearance  of  stenotic  symptoms.  Many  of  these  cases 
improve.  The  introduction  of  a  tube  into  the  inflamed  larynx  in 
measles  is  not  without  danger  of  causing  ulcerations  of  a  troublesome 
type  after  the  measles  has  run  its  course.  It  is  well  to  follow 
O'Dwyer's  advice  in  such  cases — withhold  the  tube  as  long  as  dan- 
gerous dyspnoea  is  absent.     The  use  of  apomorphine,  tartar  emetic, 


310  TEE  SPECIFIC  INFECTIOUS  DISEASES. 

or  tiirpeth  mineral,  so  popular  with  continental  physicians,  to  expel 
membrane  or  secretion,  is  of  doubtful  value. 

The  Ear. — Otitis  should  be  suspected  if  there  is  restlessness  and 
an  intermittent  course  of  temperature  without  apjDarent  cause.  Older 
children  may  indicate  the  seat  of  pain.  In  some  cases  it  may  be  nec- 
essary to  incise  the  tympanic  membrane.  The  procedure  affords 
relief  from  pain,  and  is  without  ill  effects.  Pus  or  a  few  drops  of 
serum  only  may  be  evacuated. 

Diarrhoea.- — Diarrhoea  requires  the  same  treatment  as  a  primary 
enteric  catarrh. 

Eyes,  Nose,  and  Mouth. — The  care  of  the  eyes,  nose,  and  mouth 
should  be  conducted  on  general  lines.  If  the  secretion  is  excessive, 
the  eyes  may  be  bathed  once  a  day  with  a  lukewarm  weak  saline  solu- 
tion. Unless  the  secretions  are  excessive,  the  nostrils  should  not  be 
syringed  or  douched.  If  clots  of  mucus  or  pseudomembranous  shreds 
form  in  plugs,  they  may  be  dislodged  once  a  day  by  a  nasal  washing 
with  a  suitable  hand  syringe.  The  mouth  should  not  be  washed  more 
than  once  a  day.  This  should  be  done  both  for  infants  who  are  fed 
artificially  and  for  older  children.  On  account  of  the  great  vulner- 
ability of  the  mucous  membrane  in  this  disease  the  utmost  gentleness 
should  be  exercised  lest  aphthous  ulcerations  develop. 

VARICELLA. 

(CMclcenpox;   (Ger.)    WindpocTcen.) 

Varicella  is  an  acute  infectious  disease  with  a  characteristic 
exanthematic  eruption.  It  is  distinct  from  vaccinia  or  variola,  is 
an  affection  of  childhood,  occurring  before  the  tenth  year,  rarely 
later,  and  is  transmitted  by  direct  contact  and  through  the  atmos- 
phere. It  cannot  always  be  conveyed  by  inoculation,  as  is  the  case 
with  vaccinia  or  variola.  It  does  not  protect  from  vaccinia  or  variola. 
Varicella,  vaccinia,  and  variola  have  been  observed  to  attack  the  same 
patient  successively  at  very  short  intervals.  Few  children  escape 
after  exposure,  and  one  attack  does  not  confer  immunity.  I  have 
seen  cases  of  second  attacks.  Varicella  is  an  endemic  disease,  and 
rarely  occurs  epidemically. 

Incubation.^ — Varicella  has  a  period  of  incubation  during  which 
competent  observers  have  noted  no  disturbances  (Henoch)  ;  others 
record  malaise,  coryza,  and  sore  throat.  The  author  is  inclined  to 
regard  the  prodromal  period  as  free  from  symptoms.  The  period  of 
incubation  is  usually  fourteen  days,  but  it  may  be  protracted  for 
nineteen  days. 

Symptoms. — The  symptoms  consist  of  an  exanthema,  an  enan- 
thcnia,    fever,    and   slight   malaise.      There   may   be   complications. 


VARICELLA.  311 

Previous  to  the  appearance  of  the  exanthema  there  may  be  a  slight 
febrile  movement  and  malaise,  which  in  children  may  pass  unnoticed. 
In  cases  pursuing  a  normal  course,  a  chill  with  a  marked  rise  of  tem- 
perature may  precede  the  eruption  by  fully  twelve  hours.  When 
the  eruption  appears  the  temperature  gradually  falls,  unless  another 
crop  of  papules  appears,  when  there  is  another  sharp  rise  of  tem- 
perature. Sore  throat  and  slight  malaise  may  herald  the  eruption. 
There  may  be,  as  in  measles  and  in  varioloid,  an  erythema  of  the 
surface  prior  to  the  appearance  of  the  exanthema. 

Exanthema.- — The  exanthema  consists  of  an  eruption  of  roseolar 
papules  varying  in  size  from  that  of  a  pin's  head  to  that  of  a  split 
pea.  They  first  appear  on  the  forehead  and  face,  and  spread  to  the 
trunk.  In  some  cases  larger  blotches  appear,  but  these  are  of  the 
nature  of  an  erythema,  which  may  precede  the  eruption  of  the  roseola 
by  a  few  hours.  The  roseolar  papules  have  a  characteristic  violet- 
rose  tint,  are  raised  above  the  surface,  and  are  sometimes  hard  to  the 
touch.  In  a  few  hours  the  papule  develops  on  its  summit  a  vesicle, 
which  rapidly  fills  with  lymph.  These  vesicles  become  tense,  and  if 
the  papule  is  irregular  in  shape  cover  the  whole  upper  surface  of 
the  papule.  In  many  places  the  vesicle  at  the  stage  of  its  efflorescence 
presents  an  umbilication  which  strongly  resembles  that  seen  in  the 
vaccinia  pock.  The  contents  of  the  vesicle  become  cloudy  and  then 
yellow;  the  vesicle  is  surrounded  by  a  dusky  pink  areola.  In  the 
course  of  a  day  or  two  the  cycle  is  completed,  and  the  vesicopustule 
begins  to  desiccate.     A  reddish-brown  scab  is  developed. 

Many  of  the  roseolar  papules  do  not  develop  the  vesicle  and  pus- 
tule. While  one  crop  of  papules  is  going  through  the  cycle  described 
above,  others  appear  on  various  parts  of  the  body.  It  is  character- 
istic of  varicella  to  have  the  surface  covered  with  roseolar  papules, 
papules  with  vesicles,  and  with  pustules,  in  various  stages  of  devel- 
opment. The  papules,  vesicles,  or  pustules  may  be  few  or  very 
abundant.  In  some  cases  after  the  scab  of  the  vesicle  l^as  fallen  off 
a  distinct  scar  is  left,  similar  to  that  seen  in  vaccination,  but  much 
smaller ;  it  may  persist  for  years.  The  skin  between  the  papules  and 
vesicopapules  is  normal  in  color. 

The  soft  palate  and  sometimes  the  hard  palate  may  show  a  few 
isolated  papules,  vesicles  or  vesicopustules  similar  to  those  seen  on  the 
cutaneous  surf  ace  (enanthema).  In  most  cases  there  is  an  angina,  an 
injection  of  the  conjunctivae  or  even  an  enanthema  on  the  ocular  con- 
junctiva (Henoch).  Thomas  records  varicella  papules  and  pustules 
on  the  nasal  and  vulvar  mucous  membrane  (Fig.  44). 

The  temperature  is  in  many  cases  little  raised  above  the  normal. 
In  others  it  reaches  103°  F.  (39.4°  0.)  at  the  outset  of  the  affection. 
In  rare  cases  106.5°  F.  (41.3°  C.)  has  been  observed.     As  soon  as 


312 


THE  SPECIFIC  INFECTIOUS  DISEASES. 


the  eruption  is  fully  developed  the  temperature  rapidly  becomes  nor- 
mal. The  duration  of  the  fever  varies  from  one  to  three  days.  I 
have  seen  severe  cases  in  which  the  high  temperature  persisted  fully 
a  week.  The  eruption  was  in  these  cases  accompanied  by  secondary 
pustulation. 

Other  Symptoms. — Many  infants  and  children  show  little  consti- 
tutional disturbance.  In  other  cases  there  is  lack  of  appetite  with 
excessive  irritability.  In  others,  on  account  of  the  profuse  eruption 
in  the  vulva  and  around  the  nates,  there  is  annoying  vesical  tenesmus 
and  even  rectal  tenesmus.     The  latter  condition  I  have  seen  in  a 


Pig.  44, 

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Varicella  temperature-curve  showing  successive  rises  due  to  a  new  eruption  of 
papules  and  vesicles.     Boy  aged  six  years. 


child  two  and  a  half  years  of  age,  in  whom  there  was  a  profuse  erup- 
tion of  vesicles  in  and  around  the  introitus  vaginae,  on  the  nymphae, 
and  around  the  anus.  There  is  in  some  cases  a  recrudescence  of  the 
exanthema  in  various  parts  of  the  body,  with  rises  of  temperature. 

Complications. — Gangrene  of  the  skin  with  sloughing  of  large 
areas  has  been  noted  by  some  observers  (varicella  gangrenosa).  The 
conclusion  is  inevitable  that  in  many  of  these  cases  there  must  have 
been  a  mixed  infection.     Erysipelas  is  also  a  complication. 

Nephritis. — In  many  cases  there  is  albumin  in  the  urine  to  the 
extent  of  a  trace.  Henoch  has  described  six  cases  of  varicella  compli- 
cated with  nephritis  on  the  eighth  to  the  fourteenth  day  after  the 
appearance  of  the  eruption.  In  these  the  eruption  was  profuse  and 
accompanied  by  fever;  there  was  oedema  with  albumin  and  casts  in 
the  urine.  One  case  with  fatty  liver  and  moderate  hypertrophy  and 
dilatation  of  the  left  ventricle  resulted  fatally.     Other  authors  have 


VARICELLA. 


313 


confirmed  the  observations  of  Henoch.  I  have  seen  slight  albumi- 
nuria in  some  cases  of  varicella. 

Joint-dffections. — I  have  observed  two  cases  of  varicella  with 
swelling,  pain,  and  effusion  in  one  or  both  knee-joints.  In  neither 
was  there  suppuration.  Both  cases  retrograded,  and  in  a  few  days 
the  joints  became  normal.  The  whole  picture  simulated  what  is  seen 
in  some  cases  of  scarlet  fever.     There  was  no  endocarditis. 

Otitis. — Otitis  may  occur  as  a  complication  of  severe  cases. 

Pneumonia. — Pneumonia  is  an  occasional  complication  (Fig.  45). 

Nervous  System. — I  have  recently  observed  two  cases  in  which 
after  the  exanthema  had  run  its  course,  on  the  tenth  or  fourteenth 
day  of  the  disease,  the  patients,  both  boys,  seven  and  nine  years  of 
age,  developed  increasing  sopor,  with  mild  hydrocephalus,  and  paresis 
in  all  four  extremities.  In  one  case  there  was  considerable  difficulty 
in  swallowing.  There  was  after  the  first  day  no  temperature  above 
100°  in  the  rectum.     The  symptoms  also  at  times  included  a  restless 


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Varicella  bullosa,  pneumonia,  otitis  media  purulenta.     Female  child  aged  six  years. 


delirium.  The  patients  were  uneasy  and  tossed  about.  These  were 
evidently  cases  of  complicating  polioencephalitis  and  were  mistaken 
for  possible  tubercular  meningitis.  Both  cases  made  a  good  recovery 
without  leaving  any  paralyses. 

Diagnosis. — The  diagnosis  of  varicella  should  present  few  diffi- 
culties. I  have  seen  a  number  of  cases  in  which  the  eruption  was 
not  only  very  profuse,  but  the  individual  varicella  vesicles  or  pus- 
tules were  also  very  large.  In  these  cases  there  may  always  arise 
the  question  of  differentiation  from  the  more  serious  affection,  variola 
or  varioloid,  especially  if  an  epidemic  of  smallpox  is  prevalent.  The 
diagnosis  may  even  in  some  rare  cases  remain  in  doubt  (Jlirgensen). 
In  varicella  the  temperature  is  lower  and  the  rise  shorter  in  duration 
than  in  even  a  mild  case  of  smallpox.  In  the  absence  of  an  epidemic, 
the  mildness  of  constitutional  symptoms,  discreteness  of  the  varicella 
eruption,  and  the  absence  of  any  oedema  of  the  skin  between  the 
vesicles  will  aid  us. 


314  IRE  SPECIFIC  INFECTIOUS  DISEASES. 

In  some  cases  the  eruption  of  roseola  papules  on  the  face  and 
trunk  has  not  the  characteristic  appearance  of  vesiculation  or  pustu- 
lation  seen  in  varicella.  It  is  difficult  on  account  of  the  effects  of 
the  scratching  of  the  patient  to  differentiate  the  eruption  from  pus- 
tules of  a  furuncular  type.  Under  such  conditions  a  close  inspection 
of  the  back  may  result  in  the  discovery  of  one  or  two  typical  varicella 
vesicles. 

Prognosis. — The  prognosis  is  very  good  in  varicella,  except  in 
neglected  cases,  in  which  sepsis  may  complicate  the  disease.  The 
very  rare  cases  of  nephritis  (Henoch)  should  be  borne  in  mind.  In 
private  practice  and  in  a  large  ambulatory  clinic  I  have  rarely  seen 
the  severer  types  of  this  disease.  I  agree  with  Fiirbringer  in  think- 
ing that  such  cases  raise  the  question  of  the  possibility  of  an  extra- 
neous infection. 

Treatment. — Though  the  course  of  varicella  is  mild,  the  cases 
should  be  isolated  like  those  of  any  other  infectious  contagious  dis- 
ease. We  can  never  predict  the  outcome  of  a  number  of  cases  occur- 
ring in  epidemic  form,  although  individual  cases  do  well.  If  there 
are  itching  and  tension,  the  eruption  is  covered  with  5  per  cent,  boric 
acid  ointment  applied  without  lint.  The  children  are  allowed  out  of 
doors  as  soon  as  the  temperature  has  become  normal,  the  scabs  of 
the  varicella  vesicles  or  pustules  have  fallen  off,  and  the  skin  has 
become  normal.  i 

VACCINATION. 

Vaccination  is  a  prophylactic  measure  against  variola  practised 
on  the  human  subject.  It  gives  a  certain,  though  not  lasting,  immu- 
nity against  the  disease.  It  is  accomplished  by  inoculating  the  human 
subject  with  the  contents  of  the  cowpox  vesicle. 

Cowpox  or  vaccinia  (vacca,  cow)  is  a  specific  exanthema  which 
occurs  on  the  udder  of  the  milch  cow,  hence  the  name.  Vaccinia  is 
inoculable  from  animal  to  animal,  and  also  on  the  human  subject. 
It  occurs  only  at  the  point  of  inoculation. 

Successful  vaccination  gives  the  human  subject  almost  certain 
protection  for  a  long  time  against  vaccinia  or  cowpox  and  variola  or 
smallpox. 

The  essential  cause  of  vaccinia  in  animals  and  the  human  subject  has  been 
described  by  Guarnieri  and  Kurlow  as  vaccine  corpuscles.  These  are  found  in  the 
vaccine  vesicle  and  pustule.  They  are  peculiar,  finely  punctate,  amoebic  masses  of 
protoplasm,  showing  vacuoles.  Loudon  and  Salmon,  on  the  other  hand,  deny  any 
specific  properties  to  these  corpuscles.  They  think  they  are  simply  degenerated 
leucocytes,  and  are  seen  in  other  simple  forms  of  inflammation. 

History. — Edward  Jenner  (1749-1823)  was  the  first  to  establish 
the  doctrine  of  vaccination  on  scientific  experimental  data.     He  was 


VACCINATION.  315 

the  first  to  use  humanized  vaccine — that  is  to  say,  to  inoculate  the 
human  subject  with  lymph  from  a  cowpox  vesicle,  and  then  to  utilize 
the  lymph  of  the  vesicle  in  the  human  subject  to  inoculate  others. 
This  method  has  been  abandoned.  To-day  the  lymph  used  is  obtained 
directly  from  the  animal.  The  lymph  is,  as  a  rule,  inoculated  from 
animal  to  animal  for  several  generations.  It  is  just  as  effective  as 
the  lymph  of  the  first  animal  of  the  series  inoculated.  It  is  called 
animal  lymph  or  vaccine.  The  disadvantages  of  using  humanized 
vaccine  are  many.  First,  there  is  a  natural  reluctance  among  some 
people  to  vaccinate  their  children  with  lymph  obtained  from  the 
human  subject.  Apart  from  the  popular  belief  in  the  transmission 
of  tuberculosis,  scrofula,  and  other  forms  of  disease  in  this  way, 
it  is  not  always  possible  to  exclude  an'infection,  such  as  syphilis. 
The  animal  lymph  can  be  controlled  in  its  manufacture  and  produced 
with  all  scientific  precautions.  Animal  lymph  and  human  lymph  do 
not  differ  in  the  power  to  confer  immunity  against  variola.  The 
animal  lymph  should  be  obtained  from  the  healthy  animal  in  the 
vesicular  stage  of  the  eruption;  this  is  the  fourth  or  fifth  day  of 
cowpox.  It  is  preserved  by  mixing  it  with  three  or  four  times  its 
bulk  of  glycerin.  It  may  be  put  up  for  use  on  quills  or  ivory  slips 
in  a  dry  state  or  in  small  capillary  tubes  in  the  liquid  condition. 
The  so-called  vaccine  pulp,  made  up  of  the  contents  of  the  vesicle 
and  its  epidermal  covering,  and  preserved  in  glycerin,  is  not  used  in 
this  country. 

Age  at  which  to  Vaccinate.- — Every  infant  child  should  be  vacci- 
nated. There  is  no  contraindication  except  some  acute  or  chronic 
illness.  Even  the  hemorrhagic  diathesis  is  no  contraindication. 
Vaccination  is  best  done  between  the  fourth  and  the  sixth  month, 
before  teething  has  begun  (Zimmerman).  In  an  emergency,  such  as 
the  presence  of  an  epidemic  of  smallpox,  the  newly  born  infant  may 
be  vaccinated. 

Method. — Boys  are  vaccinated  on  the  left  arm;  girls,  for  esthetic 
reasons,  may  be  vaccinated  on  the  thigh  or  calf  of  the  leg  instead, 
xhe  outer  surface  of  the  arm,  at  about  the  insertion  of  the  deltoid 
in  the  humerus,  is  usually  selected.  The  skin  is  carefully  cleansed 
with  soap  and  water,  washed  with  alcohol,  and  dried.  With  a  clean 
sewing-needle  the  skin  is  scarified  three  or  four  times  in  one  direc- 
tion, and  at  right  angles  to  the  first  scarifications.  We  should  not 
cause  bleeding,  but  only  expose  a  raw  surface.  The  scarified  area 
should  be  about  one-eighth  of  an  inch  square.  The  lymph  is  now 
rubbed  on  the  scarified  area.  If  quills  are  used,  the  vaccine  on  the 
quill  is  moistened  with  a  drop  of  distilled  water  before  inoculation. 
Scarifying  large  areas  is  likely  to  cause  excessively  large  pustules, 
with  subsequent  severe  inflammatory  reaction.     On  the  other  hand. 


316  TRE  SPECIFIC  INFECTIOUS  DISEASES. 

a  small  area  of  scarification  may  give  a  very  large  pustule.  In  other 
words,  the  size  of  the  vaccine  pustule  does  not  always  depend  upon 
the  size  of  the  area  of  scarification.  A  mixed  infection  will  give  a 
severe  reaction  with  a  very  small  area  of  scarification. 

Lymph  to  Use. — Either  the  liquid  or  the  dry  lymph  may  be  used. 
Both  are  reliable  if  recently  prepared.  If  the  lymph  is  not  fresh,  or 
there  is  carelessness  in  its  use,  the  vaccination  will  be  a  failure. 

Course. — The  great  majority  of  vaccinations  are  quite  uniform  in 
history.  There  is  an  incubation  period,  during  which  the  wound 
heals.  There  are  absolutely  no  symptoms.  This  period  usually  lasts 
three  days,  sometimes  only  two,  and  may  be  prolonged  to  four  or  six 
days.  After  this  period  there  is  the  eruptive  stage,  ushered  in  by 
the  formation  of  flat  rose-red  papules  at  the  points  of  scarification. 
The  papules  are  either  oval  or  irregularly  long.  On  the  fifth  day  a 
vesicle  appears  in  the  centre  of  the  papule  and  spreads  to  the  periph- 
ery. On  the  sixth  day  the  vesicle  takes  up  the  whole  papule,  has  a 
pearly  lustre  at  the  surface,  and  presents  a  central  umbilication 
(Jenner's  vesicles).  The  seventh  day  is  the  day  of  efflorescence;  the 
vesicle  is  filled  and  tense  with  lymph,  has  a  rose-red  areola  and  a 
hypersemic  zone  outside  this  areola ;  there  are  itching  and  tension. 
On  the  eighth  day  the  contents  of  the  vesicle  become  slightly  cloudy. 
On  the  ninth  day  the  suppuration  is  pronounced,  and  on  the  tenth 
day  the  suppuration,  swelling,  and  inflammatory  reaction  are  at  their 
height.  At  the  end  of  the  tenth  day  there  is  a  retrogression  of  all 
the  symptoms.  The  vaccine  pustule  becomes  less  angry  looking  and 
the  inflammatory  reaction  subsides.  A  crust  forms  which  may 
become  dry,  hard,  and  fall  off,  leaving  a  scar  beneath.  This  takes, 
as  a  rule,  from  ten  to  fourteen  days  (Plate  XV.). 

Fever  in  some  cases  begins  on  the  fifth  day  after  vaccination.  It 
may  be  slight  and  reach  its  height  between  the  eighth  and  the  tenth 
day.  There  may  at  this  time  be  slight  digestive  disturbances,  such 
as  vomiting  or  greenish  movements. 

The  areola  around  the  vaccine  pustule  may  spread  so  as  to  involve 
most  of  the  upper  part  of  the  arm,  or  the  inflammatory  reaction  may 
spread  over  the  entire  arm,  and  sometimes  over  the  back.  There  may 
be  enlargement  of  the  lymph-nodes  in  the  axillae.  These  lymph-nodes 
may  suppurate.  If  there  has  been  no  mixed  infection,  they  retro- 
grade with  the  pustule. 

Complications. — Complications  occur  according  to  Sobel  in  14  per 
cent,  of  vaccinations,  and  are  the  result  of  traumatism  of  the  pustule, 
mixed  infection  (that  is,  the  presence  of  impurities,  such  as  strepto- 
cocci or  staphylococci  in  the  lymph),  lack  of  cleanliness  at  the  time 
of  maturation  of  the  pustule,  and  retention  of  pus  in  a  dressing.  The 
most  common  complication  is  an  exceedingly  severe  reaction,  with  an 


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VACCINATION  317 

extensive  necrosis  of  tissue.  This  may  affect  the  fasciae  or  muscular 
layers,  causing  large  loss  of  tissue.  Among  the  rarer  complications 
of  vaccination  is  a  true  septic  infection.  In  these  cases  there  is  a 
history  of  mismanagement  of  the  pustule,  such  as  traumatism  or  the 
compression  of  the  arm  by  a  bandage.  Infection  which  manifests 
itself  in  a  remittent  febrile  curve  occurs.  In  one  case  w^hich  came 
under  my  notice  a  few  pus-corpuscles  appeared  in  the  urine,  the  elbow- 
joint  and  other  joints  became  painful  and  swollen,  and  suppuration 
in  the  joints  resulted.  These  cases  are  fatal.  There  is  a  true  osteo- 
myelitis of  the  heads  of  the  bones,  with  formation  of  pus  in  the  joints. 
In  other  cases  the  child  may  by  scratching  inoculate  itself  elsewhere, 
either  on  the  arms  or  even  lips  and  eyelids ;  the  latter  condition  has 
come  to  my  notice.  It  forms  a  very  painful  and  severe  complica- 
tion. Erysipelas  may  set  in  early  or  late  in  the  history  of  the  vacci- 
nation. It  may  spread  down  the  arm  and  forearm  on  the  trunk  and 
may  endanger  the  life  of  the  patient.  In  other  cases  there  may  be 
suppuration  of  lymph-nodes.  In  susceptible  subjects  a  rebellious 
eczema  may  appear  as  a  direct  sequence  of  the  vaccination. 

Among  the  complications  may  be  mentioned  axillary  adenitis, 
hemorrhage  into  the  pock  (trauma),  exuberant  granulations,  and 
keloid  of  the  scar.  Rosenau  found  that  the  dry  points  contain  more 
bacteria  than  glycerinized  vaccine.  All  vaccine  contains  pus-organ- 
isms. He  thinks  that  properly  prepared  glycerin  lymph  is  to  be 
preferred  to  dry  points.  The  same  investigator  examined  a  large 
number  of  samples  of  commercial  vaccine  and  failed  to  find  tetanus 
germs  in  them.  It  seems  more  likely  that  carelessness  in  dressing  or 
handling,  or  faulty  technique  in  performing  the  operation  has  been 
the  means  of  introducing  tetanus-spores,  rather  than  that  these  should 
be  present  in  the  vaccine  virus. 

Generalized  Vaccinia. — This  is  a  general  eruption  of  vaccine  pus- 
tules, which  in  rare  cases  appears  from  the  third  to  the  seventh  day 
over  the  whole  trunk  and  extremities.  It  is  really  a  generalized 
cowpox,  similar  to  the  generalized  eruption  in  the  exanthema. 
D'Espine  and  Jeandin  describe  cases  in  which  there  can  be  no  doubt 
of  the  absence  of  infection  of  the  surface  by  the  nails  or  otherwise. 
The  prognosis  in  these  cases  is  good;  there  are  no  severe  symptoms, 
and  the  fever  is  slight. 

Vaccination  Eruptions. — The  eruptions  which  follow  vaccination 
or  occur  while  the  pustule  is  still  in  course  of  development  are  of 
interest.  Sobel  has  made  an  exhaustive  study  of  these  eruptions. 
Two  per  cent,  of  the  vaccinations  are  followed  by  more  or  less  gen- 
eralized eruptions.  They  appear  while  the  local  site  of  the  vacci- 
nation is  open  or  as  late  as  eight  weeks  after  the  primary  inoculation, 
but  most  often  between  the  ninth  and  the  fourteenth  day  after  inocu- 


318  TBE  SPECIFIC  INFECTIOUS  DISEASES. 

lation.  They  have  no  relation  to  the  size  or  severity  of  the  local 
pustule,  which  may  be  normal.  Among  the  types  of  eruptions  are 
the  erythematous,  urticarial,  papular,  vesicular,  pustular,  morbilli- 
form, bullous,  pemphigoid,  and  scarlatiniform.  Auto-inoculation  by 
scratching  generally  occurs  an  inch  or  tvsro  from  the  original  site,  but 
it  may  occur  elsewhere,  as  on  the  eyelid  or  conjunctiva.  The  most 
common  type  of  generalized  eruption  is  undoubtedly  the  urticarial  in 
its  various  forms.  These  include  wheals,  papules,  bullae  and  vesico- 
papules.  The  morbilliform  are  easily  differentiated  by  the  absence 
of  fever  and  coryza  and  other  signs  of  measles.  The  scarlatinal  forms 
cause  great  uneasiness  and  elevation  of  temperature.  These  cases 
should  be  observed  for  urinary  complications  and  subsequent  desqua- 
mation, in  order  to  exclude  scarlet  fever.  Among  the  rarer  types 
are  the  ecthymatous  eruptions. 

Management. — The  management  of  a  normal  case  of  vaccination 
is  important.  We  should  protect  the  vesicle  from  traumatism  by 
m.eans  of  some  simple  contrivance,  such  as  a  shield.  If  the  areola  is 
angry  looking  and  the  redness  and  swelling  severe,  we  may  paint  it 
once  a  day  with  compound  tincture  of  benzoin.  This  is  very  soothing 
and  protects  the  surface  from  friction.  If  complications  occur,  they 
should  be  treated  on  surgical  principles.  Above  all,  there  should  be 
no  retention  of  pus  by  the  dressing.  Dressings  which  seal  the 
vaccine  pustule  hermetically  from  the  air  cause  retention,  and  are 
therefore  dangerous.  Sepsis  as  described  above  is  not  the  result  of 
vaccination,  but  of  subsequent  mismanagement. 

Revaccination. — Vaccination  should  be  repeated  after  the  lapse 
of  ten  years,  and  every  five  years  thereafter.  During  an  epidemic, 
every  one  who  has  not  been  revaccinated  should  be  vaccinated.  Im- 
munity to  variola  diminishes  as  we  reach  the  termination  of  the  first 
decade  after  the  first  vaccination.  If  the  revaccination  runs  a  typical 
course  identical  with  that  of  the  original  vaccination,  immunity  is 
generally  lasting. 

OTHEE  SPECIFIC  mFECTIOUS  DISEASES. 

TYPHOID    FEVER. 

(Abdominal  Typhus;  Ileotyphus.) 

Occurrence. — Of  222  cases  of  typhoid  fever  in  my  hospital  service, 
122  were  of  the  male  and  100  of  the  female  sex.  In  8  the  age  was 
under  2  years,  the  youngest  being  13  months;  in  42  between  2  and 
5  years  of  age;  and  9Y  between  the  5th  and  10th  years;  and  the 
remaining  Y5  were  among  children  up  to  the  14th  year  of  life.     Thus 


TYFEOID    FEFEE.  319 

20  per  cent,  of  the  patients  were  below  the  fifth  year  of  age.  It  may 
be  said  that  all  these  cases  were  diagnosed  by  modern  methods,  includ- 
ing the  Widal  agglutination  test. 

Typhoid  Fever  and  Pregnancy. — According  to  Etienne,  quoted 
by  Morse,  the  foetus  in  utero  is  born  prematurely  in  70  per  cent,  of 
the  cases  of  typhoid  fever  in  the  mother.  The  causes  of  the  abortion 
are  much  the  same  as  those  which  obtain  in  pregnant  women  suffer- 
ing from  any  infectious  disease.  The  high  temperature,  the  toxins 
in  the  circulation  of  the  mother,  and  the  death  of  the  fcetus,  all  con- 
tribute to  cause  miscarriage.  Of  12  abortions,  9  were  stillbirths,  2 
lived  four  and  1  five  days. 

Foetal  Typhoid. — There  are  two  sets  of  cases  which  prove  that 
typhoid  fever  can  be  transmitted  from  the  mother  to  the  fcetus  :  First, 
those  in  which  the  mother,  having  been  infected  with  typhoid  fever, 
expels  a  foetus  which  may  have  lived  some  hours  after  birth  and  in 
whose  organs  the  typhoid  bacillus  has  been  found,  such  as  the  cases 
of  P.  Ernst,  Giglio,  Lynch,  and  others.  The  second  set  of  cases  are 
those  in  which  the  blood  and  fluids  of  the  foetus  give  the  Widal  reac- 
tion with  bacillosis.  Such  is  the  case  of  Foster  and  Ballantyne. 
The  mother  of  this  foetus  died  of  typhoid  fever  shortly  after  deliv- 
ery. The  stomach  contents  and  the  serum  of  the  peritoneal  cavity 
gave  a  Widal  reaction.  The  bacillus  was  found  in  the  kidney,  spleen, 
and  intestinal  contents,  but  not  in  the  blood. 

Griffith's  case  was  that  of  an  infant  apparently  healthy,  though 
jaundiced,  at  birth.  When  seven  weeks  old  the  blood  of  this  infant 
gave  the  agglutination  reaction.  It  is  possible  that  in  this  case  the 
agglutinating  substance  passed  from  the  mother  to  the  fcetus  during 
the  pregnancy  without  causing  typhoid  fever  in  the  fcetus.  Thus, 
the  presence  of  the  agglutination  reaction  is  no  proof  of  typhoid  fever, 
as  it  may  be  transmitted  through  the  placenta,  and  the  foetus  thus 
escape  typhoid  fever  (Ballantyne). 

The  anatomical  changes  found  in  the  foetus  affected  by  typhoid 
fever  are  not  identical  with  those  seen  in  the  adult.  This  is  due  to 
the  fact  that  the  infection  of  the  foetus  is  hsematogenous,  which  ex- 
plains the  high  foetal  mortality.  The  spleen  is  sometimes  though 
not  always  enlarged.  The  changes  in  the  gut  are  not  characteristic, 
being  confined  to  a  few  enlarged  follicles.  The  liver  may  be  enlarged, 
and  the  kidney  may  show  hemorrhages. 

Infantile  Typhoid. — It  has  recently  been  contended  that  typhoid 
fever  is  rare  in  the  infant  or  the  child  under  two  years  of  age.  With 
the  improved  methods  of  laboratory  diagnosis  of  typhoid  fever  we 
may  shortly  be  in  a  position  to  determine  the  relative  frequency  of 
the  disease  in  the  newborn  and  the  young  infant.  Typhoid  fever 
certainly  occurs  under  the  age  of  two  years.     As  Crozer  Griffith  has 


320  TEE  SPECIFIC  INFECTIOUS  DISEASES. 

pointed  out,  we  should  think  of  the  j^ossibility  of  its  presence  in 
every  case  of  continued  remittent  fever  of  the  nursling  not  to  be 
explained  on  other  grounds.  Of  331  cases,  9  under  two  years  of  age 
were  diagnosed  by  Henoch  as  typhoid  fever.  Among  others  who 
report  cases  are  Ollivier,  l^oyes,  ISTorthrup,  and  Bell.  I  have  seen 
8  cases  under  two  years.  One  was  in  a  bottle-fed  infant  which  had 
so-called  typhoid  sepsis  with  meningitis  and  pyelitis.  In  this  case 
there  was  typhoid  bacillosis  of  the  blood  and  all  organs  without  intes- 
tinal lesions.  In  another  case  the  infant  was  on  the  breast,  the 
mother  having  typhoid  fever.  Blackader,  in  a  recent  series  of  100 
cases,  met  4  under  two  years  of  age.  Gerhardt  reports  a  case  in  an 
infant  twenty-five  days  old,  and  Blumer  1  in  an  infant  five  days  old. 
These  cases  may  be  regarded  as  either  congenital  or  post-natal  typhoid. 

Morbid  Anatomy. — It  has  been  stated  that  when  the  foetus  in  utero 
is  affected  with  typhoid  fever  the  process  is  in  the  nature  of  a  hsema- 
togenous  infection,  and  that  there  are  few  if  any  characteristic  ana- 
tomical changes.  In  young  infants  and  children  the  changes  in  the 
gut  so  characteristic  of  adult  cases  are  not  always  seen  in  their  full 
development.  The  solitary  follicles  and  Beyer's  patches  are  enlarged, 
but  ulcerations  are  seen  only  here  and  there,  and  seldom  lead  to  per- 
foration (Monti).  In  a  case  of  my  own  the  typhoid  bacilli  were 
found  in  the  blood  and  various  organs,  but  there  were  no  intestinal 
lesions.  On  the  other  hand,  in  older  children  the  changes  in  the  gut 
closely  resemble  those  of  the  adult,  as  has  been  shown  by  Henoch. 
The  mesenteric  lymph-nodes,  especially  those  in  the  vicinity  of  the 
ileocsecal  valve,  are  enlarged.  The  remaining  changes  resemble  those 
seen  in  the  adult  subject.  ~ 

Sjnnptoms. — The  invasion  of  the  disease  in  young  children  is 
rarely  with  a  chill.  More  frequently  there  are  indefinite  chilly  sen- 
sations and  mild  general  malaise.  There  are  headache,  pains  in  the 
limbs,  vertigo,  and  in  many  cases  vomiting.  The  symptoms  of  the 
period  of  invasion  are  so  very  indefinite  in  infants  and  very  young 
children  that  cases  sometimes  escape  diagnosis. 

In  other  cases,  after  a  few  days  of  malaise  the  cerebral  symptoms 
become  marked.  The  headache  is  augmented  by  delirium  at  night, 
especially  in  older  children,  and  stupor  is  present.  In  younger  chil- 
dren the  period  of  invasion  may  simulate  a  pneumonia.  In  fact, 
these  cases  begin  as  pneumonia,  and  it  is  only  on  careful  considera- 
tion of  the  clinical  symptoms — the  predominance  in  a  few  cases  of 
cerebral  symptoms  or  the  enlarged  spleen,  and  the  presence  of  roseola 
later  on,  with  the  elevation  of  temperature — that  we  are  led  to  think 
of  typhoid  fever. 

In  some  of  these  pneumonic  cases  there  are  none  of  the  charac- 
teristic features  of  typhoid.     There  is  no  roseola,  no  splenic  enlarge- 


TYPHOID    FEVEE.  321 

ment,  no  epistaxis,  but  there  may  be  diarrboea.  During  an  epidemic 
only  the  systematic  examination  of  the  blood  for  the  Widal  aggluti- 
nation reaction  will  reveal  these  cases.  Such  a  case  is  the  following : 
A  child,  five  years  of  age,  was  admitted  to  my  hospital  service  with 
an  indefinite  previous  history.  Temperature  104.6°  F.  (40.3°  C), 
pulse  140,  and  respirations  30.  There  was  apathy,  also  a  broncho- 
pneumonia in  the  upper  lobe  of  the  left  lung.  This  case  gave  a  very 
positive  Widal  reaction  early  in  the  disease.  The  spleen  became  pal- 
pable four  days  after  admission.  In  another  case,  of  a  child  four 
years  of  age,  signs  of  a  lobar  pneumonia  of  the  upper  lobe  of  the  left 
lung  were  present  without  any  roseola,  enlarged  spleen,  diarrhoea,  or 
abdominal  symptoms.  On  the  fifth  day  of  the  disease  the  Widal 
reaction  became  positive  in  a  dilution  of  1:50.  This  child  died  on 
the  sixth  day  of  the  disease,  with  increasing  signs  of  pneumonia  and 
a  positive  Widal  reaction  of  1 :  350. 

Many  of  these  cases  of  typhoid  fever  in  older  children  become 
comatose  after  the  first  week.  Such  a  case  was  admitted  to  my 
wards.  The  onset  was  with  headache  and  fever.  There  was  no  vom- 
iting, epistaxis,  or  chill.  The  child  became  unconscious,  with  a  tem- 
perature of  106°  r.  (41.1°  C),  rigidity  of  the  muscles  of  the  neck, 
increased  reflexes,  ankle-clonus,  Kernig's  symptom,  and  enlarged 
spleen.  This  case  gave  a  positive  reaction  to  the  Widal  test,  and 
lumbar  puncture  failed  to  reveal  anything  characteristic  in  the  fluid 
withdrawn. 

The  invasion  is  not  characteristic  in  infants.  In  exceptional 
cases  (Blackader)  a  convulsion  is  the  first  symptom  noted.  In  some 
cases  there  may  be  a  simple  continued  fever,  with  diarrhoea,  without 
other  symptoms.  In  a  case  reported  by  Crozer  Griffith  the  roseola 
and  the  enlarged  spleen  were  present. 

The  subsequent  history  of  a  case  varies  with  the  character  of  the 
infection.  In  the  forms  which  have  a  slow,  gradual  onset  the  chil- 
dren remain  for  a  time  in  good  physical  condition.  During  the  first 
week  the  sensorium  is  clear,  the  tongue  is  coated,  and  the  face  color 
is  good ;  the  spleen  may  be  readily  palpable,  the  roseola  appears,  and 
there  may  be  diarrhoea  or  constipation.  In  some  cases  the  iliac  ten- 
derness is  marked ;  in  others  absent.  It  may  not  be  possible  to  deter- 
mine the  presence  of  ileocsecal  tenderness  in  young  children.  The 
symptoms  after  the  first  week  may  be  augmented  by  delirium  at 
night;  in  older  children  this  delirium,  which  has  much  the  same 
character  as  in  the  adult,  is  also  present  during  the  day.  Children 
from  five  to  seven  years  of  age  are  more  likely  to  have  the  quiet  form 
of  delirium,  while  older  children  are  noisy  and  try  to  get  out  of  bed. 

The  course  of  pneumonic  cases  is  noteworthy.  Resolution  is 
tardy  in  those  cases  which  recover.     To  the  symptoms  of  pneumonia 

21 


322 


TEE  SPECIFIC  INFECTIOUS  DISEASES. 


are  added  after  a  time  those  of  typhoid  fever — roseola  and  enlarged 
spleen.  The  temperature-curve  is  not  characteristic,  and  resembles 
that  of  the  sustained  remittent  type  (Fig.  46).  In  some  cases 
pleurisy  may  be  present. 

In  the  new^ly  born  infant  to  whom  the  fever  has  been  conveyed  in 
utero  the  picture  of  the  disease  is  unlike  that  seen  in  older  infants 
and  children.  The  symptoms  resemble  those  of  sepsis  of  the  new- 
born. Thus  in  the  case  published  by  Blumer  the  first  symptom  of  the 
disease  was  an  uncontrollable  hemorrhage  from  the  vagina.  Before 
death  this  was  supplemented  by  hemorrhages  into  the  skin  and  from 
the  gTims. 

The  cases  of  typhoid  fever  in  infancy  thus  far  recorded  by  Morse, 

Fig.  46. 


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"ESP.               s   ss      ss      s    §    ?    S!    «    sTs    s    s    s      3      as    ^n    s    s    s    s      s    sssss 

Typhoid  fever  which  began  as  a  lobar  pneumonia  in  a  girl  four  years  of  age.     Consoli- 
dation of  the  lower  lobe  of  the  left  lung ;  death  on  the  tenth  day  of  the  disease. 


Crozer  Griffith,  Blackader,  and  the  author,  may  be  divided  into  two 
classes :  those  in  which  there  is  a  mild  diarrhoea  with  distention  of  the 
abdomen,  roseola,  and  enlarged  spleen ;  and  those  which  present  cere- 
bral symptoms.  The  latter  develop  coma.  In  one  of  my  cases  there 
were  meningitism,  a  distended  abdomen,  rose  spots,  and  enlarged 
spleen.  In  both  forms  there  are  severe  and  mild  types.  Cases  in 
which  the  temperature  rarely  rises  about  104°  F.  (40°  C.)  recover, 
while  those  with  a  higher  temperature  may  be  fatal. 

Roseola. — In  children,  as  in  the  adult,  the  roseolar  papules  are 
seldom  absent.  In  some  cases  their  number  is  large,  while  in  others 
they  are  few  and  widely  scattered  over  the  surface.  They  may 
appear  in  successive  crops,  and  reappear  in  the  relapse.  Occasion- 
ally the  roseola  is  preceded  by  a  diffuse  erythema  closely  resembling 
the  scarlet  fever  eruption.     The  roseola  may,  as  in  the  adult,  appear 


TYPEOIB    FEVEB. 


32,' 


on  the  third,  fifth,  or  tenth  day,  and  may 
end  of  the  second  week,  after  which  it 
gradually  fades,  leaving  a  pigmented 
area.  The  eruption  is  sometimes  so 
profuse  as  to  resemble  the  eruption  of 
typhus.  It  may  be  profuse  in  cases 
in  which  the  cerebral  symptoms  are 
marked.  I  have  seen  typhoid  fever 
with  severe  cerebral  symptoms,  but  with 
an  eruption  very  sparse  or  entirely  ab- 
sent at  the  height  of  the  disease.  In 
severe  delirious  cases,  hemorrhagic  areas 
appear  on  the  bony  prominence  of  the 
shoulders  and  extremities.  Petechise 
are  common.  In  protracted  cases  ex- 
tensive purpuric  areas  appear  on  the 
abdomen.  These  hemorrhagic  cases  are 
not  necessarily  fatal. 

Enlarged  Spleen.  —  The  enlarged 
spleen  is  the  most  common  physical  sign. 
At  the  o'utset  of  the  disease  it  is  not 
always  easy  to  palpate  the  spleen.  This 
is  especially  true  of  younger  children. 
The  enlarged  spleen  is  present  not  only 
in  older  children,  but  also  in  cases  of 
foetal  typhoid  fever.  I  have  seen  the 
enlargement  persist  for  weeks  after  con- 
valescence. In  one  case  the  spleen  could 
be  distinctly  felt  below  the  border  of  the 
ribs  for  a  long  time  after  recovery. 

In  some  forms  of  relapse  the  spleen 
enlarges  after  having  diminished  to 
the  normal  size.  Cases  in  which  the 
spleen  remains  enlarged  a  long  time  are 
likely  to  have  slight  rises  of  tempera- 
ture of  short  duration.  Typical  relapses 
without  enlargement  of  the  spleen  may 
occur.  The  fact  that  the  spleen  con- 
tinues enlarged  after  the  temperature 
has  become  normal  does  not  always  indi- 
cate the  approach  of  a  relapse. 

Temperature. — An  elevation  of  tem- 
perature in  young  children  is  usually 


even  be  delayed  until  the 


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324  TRE  SPECIFIC  INFECTIOUS  DISEASES. 

not  noticed  by  those  about  the  child  during  the  first  eight  days. 
Children  rarely  complain  of  slight  malaise,  and  a  rise  of  a  degree 
or  even  more  above  the  normal  may  escape  notice ;  as  a  result,  the 
impression  is  prevalent  that  the  temperature  during  the  first  week 
does  not  follow  the  typical  curve.  The  cases  which  I  have  observed 
sufiiciently  early,  and  which  were  not  complicated  with  pneumonia, 
showed  during  the  first  week  the  gradual  rise  seen  in  the  adult  (Fig. 
47).  This  gradual  daily  rise  of  temperature  is  also  seen  in  relapses. 
On  each  day  the  temperature  at  its  highest  point  is  higher  than  on  the 
previous  day. 

After  the  first  week  the  temperature  is  likely  to  show  a  remittent 
curve  with  a  sustained  maximum  point.  After  the  second  week  the 
temperature  may  remit,  gradually  falling,  or  intermit ;  frequently  it 
remains  high  for  weeks,  with  daily  remissions.  By  the  end  of  the 
second  week  it  reaches  104°  to  105°  F.  (40°  to  40.5°  C.)  at  its 
highest.  In  the  course  of  the  third,  fourth,  and  fifth  weeks  it  may 
range  a  degree  lower,  with  remissions  to  101°  F.  (38.3°  C),  not 
reaching  the  normal.  If  the  case  is  protracted,  the  temperature  may 
persist  into  the  sixth  week,  running  up  as  high  as  106°  F.  (41.1° 
C),  falling  fully  five  degrees  twice  daily.  In  one  case  the  tempera- 
ture did  not  become  normal  until  the  eighth  week.  Even  at  this  late 
period  there  may  be  relapses.  In  many  cases  the  temperature  falls 
to  the  normal  after  six  or  seven  weeks,  or  becomes  subnormal,  and 
then  after  an  interval  of  a  few  days  or  a  week  rises  and  fluctuates  a 
degree  or  more  above  the  normal.  This  continues  for  a  few  days, 
the  temperature  remitting  to  the  normal  or  near  the  normal.  These 
post-typhoidal  fluctuations  are  sometimes  mistaken  for  i^elapses. 
They  are  rather  to  be  attributed  to  inanition,  or  are  the  result  of 
slight  absorption  from  the  gut.  In  a  large  number  of  cases  the  first 
sign  of  convalescence  is  a  subnormal  temperature.  On  the  other 
hand,  the  temperature  may  be  subnormal  for  a  week  or  more  and 
relapse  follow  (Fig.  49). 

It  may  be  said  that  as  a  rule  the  first  week  of  typhoid  fever  in 
children  shows  a  gradual  rise  of  temperature.  The  subsequent  tem- 
perature is  sustained,  remitting  two  or  more  times  daily.  This  curve 
may  last  one,  two,  or  more  weeks.  In  other  words,  there  is  no  charac- 
teristic temperature-curve.  In  relapses  the  temperature  rises  grad- 
ually from  day  to  day.  Among  the  causes  which  may  give  rise  to  a 
slight  temporary  elevation  of  temperature  is  constipation.  A  lobar 
pneumonia  or  a  bronchopneumonia  will  cause  a  persistence  of  the 
high  temperature,  as  will  also  other  conditions,  such  as  otitis. 

The  inverted  type  of  temperature-curve  is  described  by  Henoch. 
The  morning  temperature  is  higher  than  the  evening,  or  there  may 
bo  a  rise  at  3  a  m.  or  6  a.  m.,  a  fall  in  the  forenoon,  with  a  rise  again 


TYFHOIB    FEVER. 


325 


at  noon,  and  a  fall  toward  evening.  Such  a  curve  may  be  followed 
within  a  day  or  two  by  the  usual  fall  in  the  morning  and  rise  toward 
evening.  These  fluctuations  occur  at  the  height  and  at  the  decline 
of  the  disease. 

HemoiThages. — Hemorrhages  from  the  bowel  are  not  so  common 
in  children  as  in  the  adult.  I  have  seen  persistent  hemorrhages  in 
only  8  out  of  222  cases.  In  one  case  there  was  post-typhoidal  ulcer- 
ative colitis.  The  bowels  may  be  constipated,  normal,  or  diarrhoeal. 
The  number  of  stools  varies.  In  the  majority  of  cases  diarrhoea  is 
absent.  In  some  the  temperature  in  convalescence  may  rise  a  degree 
or  more  for  a  day  or  two.  In  these  cases  there  may  be  fecal  accumu- 
lation due  to  incomplete  evacuation  of  the  gut. 

Fig.  48. 


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Typhoid  fever  of  short  duration  in  a  boy  siz  years  of  age. 

Pain, — Sensitiveness  in  the  ileocsecal  region  is  very  difiicult  to 
determine  in  young  children.  In  older  children  it  is  sometimes 
marked,  and  indicates  ulcerative  processes  in  that  region  or  in  the 
neighborhood  of  the  appendix. 

Pain  as  a  symptom  in  typhoid  fever  in  the  adult  occurs  in  two- 
fifths  of  the  cases  observed  by  McCrae.  In  childhood  it  is  not  as 
common  a  symptom,  inasmuch  as  young  children  are  not  apt  to  com- 
plain of  pain.  It  is  observed,  however,  though  the  exact  percentage 
of  cases  cannot  be  stated,  on  account  of  the  peculiarity  of  the  subjects 
dealt  with.  In  the  adult  abdominal  pain  in  the  course  of  typhoid 
fever  is  present  in  complicating  pleurisy  and  pneumonia ;  or  it  may 
be  due  to  a  distended  bladder,  the  ingestion  of  solid  food,  vomiting, 
fsecal  impaction,  diarrhoea,  appendicitis,  peritonitis,  cholecystitis, 
abscess  of  the  liver,  phlebitis  of  the  abdominal  veins,  and  hemorrhage. 

In  childhood  some  of  these  conditions  may  be  present,  accom- 
panied by  abdominal  pain.  In  the  cases  observed  by  the  author 
cholecystitis,  appendicitis,  perforating  ulcers,  peritonitis,  impaction 
of  fseces,  and  vomiting  could  be  fixed  on  as  a  causal  factor  in  the  pro- 
duction of  the  pain.     Pain  not  due  to  perforation,  appendicitis  or 


326  THE  SPECIFIC  INFECTIOUS  DISEASES. 

colecystitis,  as  a  rule,  is  general  in  its  location.  It  may  be  accom- 
panied by  meteorism,  or  may  be  present  with  a  retracted  abdomen. 
I  have  seen  it  in  some  cases  preceded  by  vomiting;  in  other  cases  no 
snch  symptom  was  present.  In  childhood  it  is  particularly  notice- 
able that  pain  not  due  to  perforation  is  unaccompanied  by  a  rise 
of  pulse,  and  certainly  not  by  a  rise  of  temperature.  I  have  seen  very 
severe  abdominal  pain,  necessitating  the  administration  of  opiates, 
without  the  least  disturbance  of  the  pulse,  respiration,  or  temperature. 
This  latter  condition  is  apt  to  occur  in  nervous,  hypersesthetic  chil- 
dren. The  pain  due  to  perforation  will  be  described  elsewhere.  I 
have  seen  one  case  where  intense  pain  was  caused  by  a  distended  gall- 
bladder with  cholecystitis,  the  diagnosis  being  confirmed  at  the  oper- 
ating table.  In  this  case  the  pain  was  distinctly  localized,  and  there 
was  temperature  due  to  the  hepatic  condition. 

Otitis. — Otitis  is  not  uncommon.     I  have  seen  several  cases. 

Mastoiditis. — I  have  observed  mastoiditis  in  11  cases,  1  of  which 
resulted  fatally  in  the  second  week  of  the  disease. 

Parotitis. — I  observed  parotitis  in  4  cases. 

Tongue. — -The  tongue  of  children  with  typhoid  fever  resembles 
that  of  the  adult.  It  is  at  first  coated,  and  is  protruded  in  a  tremu- 
lous manner;  subsequently  the  epithelium  is  thrown  off  and  the 
papillae  become  prominent.  In  some  cases  the  tongue  resembles  the 
so-called  strawberry  tongue  seen  in  scarlet  fever.  At  the  height  of 
the  disease  it  may  become  dry  and  fissured,  and  sordes  may  collect 
on  the  teeth.     The  lips  become  fissured  and  bleed  easily. 

Nervous  SymptoTns. — The  nervous  symptoms  of  older  children 
resemble  those  of  the  adult.  With  younger  children  sopor  is  the  rule 
and  delirium  is  infrequent.  Melancholia  or  depression  is  occasionally 
met  with  in  convalescence,  usually  in  girls  of  hysterical  temperament. 

The  Heart. — In  a  recent  epidemic  of  typhoid  many  cases  showed 
systolic  apex-murmurs.  These  murmurs  were  loudest  over  the  base, 
close  to  the  sternum,  or  over  the  pulmonary  orifice.  Such  murmurs 
are  myocarditic.  In  one  case  there  was  a  loud  musical  systolic 
murmur  heard  over  the  apex  of  the  heart.  It  was  also  heard  at  the 
base  of  the  heart.  The  murmur  appeared  early  in  the  third  week. 
There  was  also  a  pleuropericardial  friction-sound.  Post-mortem  ex- 
amination revealed  myocarditis  and  pleuropericardial  adhesion. 

The  Lungs. — The  occurrence  of  lobar  or  bronchopneumonia  late 
in  the  course  of  typhoid  is  serious.  At  this  time  the  patient's  powers 
of  resistance  are  greatly  diminished.  Especially  grave  are  the  cases 
which  show  a  sustained  high  temperature  for  two  or  three  weeks,  and 
then  develop  pneumonia.  If  with  the  pneumonia  there  are  extensive 
henaorrhages  under  the  skin  at  the  situation  of  the  bony  prominences, 
the  outlook  is  grave.  In  such  a  case  I  have  seen  a  pneumonia  involve 
the  wliole  lobe  of  the  limg  in  consolidation  within  a  few  hours. 


TYPHOID    FEVEE. 


327 


The  Blood. — In  children,  as  in  the  adult,  the  number  of  red  blood- 
cells  diminishes,  and  reaches  the  lowest  point  at  the  end  of  the  febrile 
period.  The  hgemoglobin  also  is 
diminished.  The  leucocytes  are  di- 
minished from  the  outset  until  con- 
valescence, but  increase  after  it  is 
established.  In  one  of  my  cases 
their  number  fell  to  3500,  and  then 
rose  to  12,400.  In  a  case  compli- 
cated with  extensive  ulceration  in 
the  gut  and  bronchopneumonia  they 
numbered  30,000.  In  fatal  cases 
complicated  with  lobar  pneumonia 
I  have  found  them  as  low  as  4500. 
According  to  Thayer,  the  polynu- 
clear  neutrophiles  steadily  diminish 
as  convalescence  approaches,  while 
the  mononuclear  lymphocytes  and 
eosinophiles  increase.  With  the  es- 
tablishment of  convalescence  blood 
conditions  return  to  the  normal. 

Relapses. — A  relapse  is  a  grad- 
ually ascending  temperature-curve 
extending  over  a  week  or  longer 
after  the  temperature  has  been 
normal  for  a  time  (Fig.  49).  A 
relapse  was  noted  in  7  of  46  cases 
of  my  last  series.  In  all,  it  was 
mild  and  no  serious  results  followed. 
•  On  the  other  hand,  a  prolonged  low 
febrile  curve  causes  great  emacia- 
tion in  children.  Undue  impor- 
tance has  been  attached  to  the  con- 
dition of  the  spleen  in  these  cases. 
The  percentage  of  relapses  varies 
with  the  nature  of  the  prevailing 
epidemic.  Blackader  records  15  re- 
lapses in  100  cases,  and  Henoch  44 
in  375  cases.  Apparently  relapses 
occur  independently  of  the  mode  of 
treatment  and  diet. 

Complications  and  Sequelae. — Skin. 
— Subcutaneous  abscesses  may  oc- 
cur, and  onchyia  is  common.     Ery- 


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328  TBE  SPECIFIC  INFECTIOUS  DISEASES. 

sipelas  and  parotitis  are  uncommon.  (Edema  may  be  confined  to  the 
scrotum,  or  during  defervescence  the  whole  surface  of  the  body  may 
be  oedematous.  In  a  case  of  scrotal  oedema  coming  under  my  observa- 
tion there  were  no  casts  or  albumin  in  the  urine ;  the  leucocytes  were 
diminished.  Henoch  attributes  oedema  to  cardiac  weakness  rather 
than  to  nephritis. 

Diphtheria. — Diphtheria  is  a  very  serious  complication.  I  have 
observed  it  in  2  cases. 

The  Lungs. — Bronchitis  is  a  frequent  complication.  In  the  later 
stages  of  the  disease  in  younger  children  it  is  likely  to  develop  into 
bronchopneumonia,  especially  in  cases  in  which  the  course  of  the  dis- 
ease has  been  protracted.  Pneumonia  may  occur  in  older  children 
at  the  outset  or  in  course  of  the  disease.  Gangrene  of  the  lung  is 
mentioned  by  Henoch  as  a  rare  complication. 

Arthritis. — Arthritis  is  uncommon.  Usually  only  one  joint  is 
affected.  It  occurs  in  the  post-typhoidal  period  and  runs  a  favorable 
course. 

Nervous  System. — Among  the  nervous  symptoms  which  compli- 
cate or  follow  typhoid  fever  are  aphasia,  amblyopia,  ataxia  of  the 
lower  extremities,  paralyses  of  various  sets  of  muscles,  double  ptosis, 
and  hemiplegia.  In  hysterical  children  there  may  be  a  post-typhoidal 
melancholia.  In  others  stupidity  may  persist  for  a  time.  Recovery 
usually  takes  place  in  all  forms  of  paralysis,  aphasia,  and  melan- 
cholia. The  paralyses  are  possibly  due  to  a  neuritis  of  toxic  origin, 
as  is  the  case  vdth  the  other  infectious  diseases  or  an  encephalitis. 
Hemiplegia  occurs  only  as  a  result  of  embolism  (Henoch).  I  have 
seen  cases  of  ataxia  and  marked  melancholia.  The  children  made  an 
excellent  recovery.  In  one  case,  a  boy  of  four  years,  catalepsy  was 
present  for  a  period  of  five  weeks  after  the  temperature  had  become 
normal. 

Meningitis  occurred  in  an  infant  of  13  months. 

Kidneys. — ISTephritis  of  a  mild  type  may  occur  and  persist  long 
into  convalescence. 

Pyuria  occasionally  occurs  but  is  usually  of  no  severity  and 
requires  no  treatment. 

Perforation  of  the  Intestine  in  Typhoid  Fever. — The  frequency  of 
perforation  of  the  intestine  in  children  affected  with  typhoid  fever, 
according  to  all  available  statistics,  is  1.2  per  cent,  of  all  the  cases. 
Of  my  own  material  of  222  cases  there  were  6  of  perforation,  in  5 
of  which  the  diagnosis  was  confirmed  by  operation  (2.7  per  cent.). 
In  the  adult  subject  the  frequency  is  1  to  2.5  per  cent,  of  all  cases. 
Therefore,  in  the  severer  forms  of  typhoid  fever  in  children,  perfora- 
tion of  the  intestine  is  almost  as  frequent  as  in  the  adult. 

Time. — Most  cases  of  perforation  occur  in  the  third  week,  some 


TYPHOID    FEVER.  329 

in  the  second  week  and  least  frequent  are  those  in  the  first  week  of 
the  disease.     One  of  my  cases  occurred  in  the  sixth  week. 

Symptoms. — Perforation  may  occur  with  a  slow,  insidious  onset, 
or  an  acutely  abrupt  one.  If  there  is  active  delirium  of  the  low  mut- 
tering type,  it  is  impossible  to  fix  the  time  of  onset  and  the  diagnosis 
becomes  apparent  only  when  peritonitis  has  made  headway.  In  one 
of  my  cases  in  which  the  onset  was  insidious,  the  pain  was  com- 
plained of  only  six  hours  before  the  operation  and  yet  it  was  found 
that  peritonitis  was  then  far  advanced.  In  this  case  the  day  before 
the  operation,  the  patient  was  somnolent,  pale,  and  complained  of 
anorexia.  Vomiting  appeared,  followed  by  a  drop  in  the  tempera- 
ture, then  pain  and  abdominal  rigidity  fully  twelve  hours  after  the 
onset,  as  subsequent  history  proved.  In  a  case  of  brusque  onset,  the 
symptoms  appeared  in  the  forty-third  day  of  the  disease.  The  tem- 
perature had  been  normal  since  the  fourth  week  of  the  disease.  Pain 
localized  around  the  umbilicus  was  the  first  abrupt  symptom;  with 
this  there  was  abdominal  tenderness,  and  distension  with  disappear- 
ance of  the  liver  dulness.  The  temperature  rose  to  104°,  the  pulse 
from  104  to  128.  In  another  case  with  abrupt  onset,  vomiting  fol- 
lowed by  pain  and  abdominal  tenderness  was  the  first  symptom. 
Thus  the  symptoms  and  mode  of  onset  make  each  case  a  matter  of 
individual  study. 

Pain  may  be  preceded  by  a  chill  or  vomiting.  It  may  be  slight, 
sharp  or  intense,  or  paroxysmal  and  may  not  reach  its  greatest  inten- 
sity for  24  hours  after  the  perforation.  Delirious  patients  do  not 
complain  of  pain.  Abdominal  tenderness,  even  to  slight  palpation, 
accompanies  the  pain,  as  does  rigidity.  Even  slight  rigidity  is  diag- 
nostic. Distention  is  present  in  most  cases,  though  in  some  there 
may  be  retraction. 

If  there  is  fluid  in  the  peritoneal  cavity  this  will  be  demonstrated 
by  movable  dulness  in  the  flanks  and  indicates  advanced  peritonitis 
or  peritoneal  reaction. 

Disappearance  of  liver  dulness  with  accompanying  abdominal 
distention  demonstrates  the  escape  of  intestinal  gases  into  the  free 
abdominal  cavity. 

A  sharp  fall  in  the  temperature  followed  by  an  equally  sharp  rise 
is  very  significant  when  present  with  other  symptoms,  for  a  fall  of 
the  temperature  alone  is  not  diagnostic. 

In  addition  to  the  symptoms  just  noted  as  marking  the  onset  of 
perforation  in  typhoid  fever,  there  is  an  increase  in  the  number  of 
leucocytes.  This  was  true  of  all  my  cases.  In  one  case  the  leuco- 
cytes mounted  from  6000  to  7000  to  10,000  to  the  c.mm.,  and  in 
another  to  13,000  to  the  c.mm.  With  all  of  the  above  symptoms  the 
respirations  became  rapid  and  shallow,  due  to  the  peritonitis.     The 


330  THE  SPECIFIC  INFECTIOUS  DISEASES. 

prostration  is  evident  even  to  collapse.  Tlie  patients  lie  prone  and 
resent  interference. 

Diagnosis.  — The  diagnosis  of  perforation  of  the  intestine  in 
typhoid  fever  must  therefore  rest  on  the  advent  in  a  patient,  otherwise 
doing  well,  of  pain  preceded  bj  chill,  vomiting  or  prostration,  abdom- 
inal distention  and  tenderness  with  a  drop  in  the  temperature  fol- 
lowed by  a  subsequent  rise.  A  rise  in  the  pulse  and  respirations,  dis- 
appearance of  liver  dulness  with  subsequent  appearance  of  fluid  in 
the  peritoneal  cavity,  leucocytosis  and  prostration. 

I  have  seen  several  cases  in  children  who  were  operated  on  with 
the  mistaken  idea  that  there  was  a  primary  appendicitis.  In  these 
there  was  a  typhoidal  ulceration  of  the  appendix  without  perforation. 
The  pain  which  was  referred  to  the  appendix  misled  the  physician. 

Prognosis. — The  prognosis  in  intestinal  perforation  complicating 
typhoid  fever  in  children  varies  with  the  time  which  has  elapsed 
from  the  onset  of  the  perforation  to  the  treatment.  Fitz  has  shown 
that  if  left  alone  5  per  cent,  of  the  cases  in  adults  recover.  In  chil- 
dren we  have  no  corresponding  statistics,  except  that  of  my  6  cases  1 
recovered.  This  was  an  undoubted  case  of  perforation  in  which  the 
inflammation  localized  itself  to  the  right  iliac  fossa.  Elsberg  has 
included  my  cases  in  statistics  of  25  cases  of  typhoidal  perforation  in 
children  with  operative  interference,  in  which  the  percentage  of 
recovery  was  64  per  cent.,  as  compared  with  22.4  per  cent,  in  the 
adult.  The  prognosis,  therefore,  in  children,  in  mixed  statistics,  is 
apparently  more  favorable  than  in  the  adult. 

Duration  of  the  Disease. — The  duration  of  typhoid  fever  varies 
within  wide  limits.  Henoch,  in  his  tabulation  of  more  than  200 
cases,  shows  that  the  longest  duration  was  seventy  days ;  the  shortest 
seven  to  nine  days.  In  my  own  cases  the  duration  varied  widely,  if 
the  rises  in  temperature  were  taken  into  account.  The  average  dura- 
tion was  four  weeks  and  three  days.  The  shortest  case  lasted  ten 
days,  and  the  longest  lasted  eleven  weeks. 

Diagnosis. — Enough  has  been  said  to  show  that  the  diagnosis  of 
typhoid  fever  in  infancy  and  childhood  is  at  times  very  difficult. 
With  young  children  enteritis,  pneumonia,  meningitis,  and  even 
appendicitis  may  simulate  typhoid  fever  in  their  onset.  Cases  which 
begin  as  a  pneumonia  are  especially  difficult  of  diagnosis.  The  cere- 
bral forms  of  typhoid  fever  may  closely  resemble  meningitis.  The 
history  is  very  important.  The  onset  of  typhoid  fever  is  gradual, 
the  cerebral  symptoms  increasing  in  intensity  as  the  disease  progresses. 
An  enlarged  spleen  and  a  few  roseolar  papules  will  be  of  service  in 
making  a  diagnosis,  but,  on  the  other  hand,  an  enlarged  spleen  is 
common  to  many  conditions  of  infancy  and  childhood.  In  the  most 
puzzling  cases,  such  as  those  simulating  enteritis  of  non-typhoidal 
nature,  the  roseola  may  at  the  outset  be  absent. 


T¥PEOID    FEVEB.  331 

111  a  doubtful  case  the  Widal  agglutination  blood-test  should  be 
made  daily  to  clear  up  the  diagnosis.  In  many  cases  this  reaction 
is  the  only  clue  to  the  condition.  During  the  prevalence  of  an  epi- 
demic every  case  of  pneumonia  or  doubtful  meningitis  or  enteritis 
should  be  subjected  to  this  test. 

Widal  Agglutination  Reaction. — The  Widal  agglutination  reac- 
tion is  of  greater  utility  in  rnaking  a  positive  diagnosis  of  typhoid 
fever  in  children  than  in  adults.  The  fact  that  an  enlarged  spleen 
may  be  due  to  various  causes,  such  as  rickets,  the  occurrence  of  fevers 
of  a  remittent  or  continued  type,  possibly  due  to  otitis,  enteritis,  pneu- 
monia, and  the  prevalence  of  diarrhoea  of  all  kinds  in  infants  and 
children,  tend  to  make  the  Widal  test  of  inestimable  value. 

In  a  paper  based  on  84  of  my  cases  of  typhoid  fever  in  infants 
and  children,  Gershel  found  the  reaction  positive  in  81.  Three  hun- 
dred and  twenty-nine  examinations  in  all  were  made.  Thirteen  per 
cent,  of  the  tests  were  positive  at  the  end  of  the  seventh  day,  63  per 
cent,  on  the  fifteenth  day,  and  89  per  cent,  on  the  twenty-fifth  day 
of  the  disease.  The  reaction  was  negative  in  only  3  cases  which 
gave  the  clinical  symptoms  of  typhoid  fever.  These  figures  corre- 
spond to  those  obtained  by  Blackader  in  a  smaller  number  of  cases. 
A  negative  reaction  unless  the  examinations  have  been  repeated  over 
a  leng-th  of  time  is  of  no  significance  as  excluding  typhoid  fever, 
whereas  a  positive  reaction  is  absolutely  pathognomonic  of  the  dis- 
ease. In  a  few  cases  the  reaction  was  not  obtained  until  the  close  of 
the  disease,  when  the  temperature  had  been  normal  for  some  days. 
In  another  case  of  a  child  of  three  years,  the  reaction  was  not  obtained 
until  a  relapse  had  occurred. 

Blood- cultures.- — If  in  a  given  case  a  blood-culture  can  be  made, 
a  positive  culture  of  typhoid  bacilli  may  be  established,  even  before 
the  Widal  reaction  is  obtained.  Blood-cultures  are  available  in  cases 
of  negative  Widal  reactions. 

The  Ehrlich  Diazo  Reaction  in  the  Urine. — Thirty-three  cases 
were  exam.ined  with  reference  to  this  reaction.  The  fifth  day  was  the 
earliest  day  on  which  it  was  obtained.  In  the  majority  of  cases  the 
reaction  was  present  from  the  seventh  to  the  tenth  day  of  the  disease. 
The  latest  appearance  was  on  the  forty-seventh  day  from  the  outset 
of  the  disease.  The  reaction  was  absent  in  15  per  cent,  of  the  cases. 
In  all  of  the  cases  in  which  the  Ehrlich  reaction  was  obtained  the 
Widal  test  was  positive,  and  appeared  in  the  first  two  weeks  of  the 
disease.  The  diazo  reaction  may  appear  before  the  Widal  reaction, 
but  in  some  cases  the  contrary  is  true.  In  conclusion,  it  may  be  said 
that  in  the  presence  of  symptoms  and  signs  of  typhoid  fever  the  diazo 
reaction  is  an  aid  to  diagnosis,  although  not  pathognomonic  of  the 
disease. 


332  TKE  SPECIFIC  INFECTIOUS  DISEASES. 

Of  the  clinical  signs  pointing  to  typhoid  fever,  the  character  of 
fever  aids  us  but  little.  In  the  third  week  it  may  become  intermit- 
tent, thus  simulating  malarial  fever.  In  other  cases  the  fever  may 
be  sustained  with  daily  remissions  until  the  fifth  week.  Typhoid 
fever  with  great  ileocsecal  tenderness  and  pain  may  closely  simulate 
appendicitis.  A  continued  fever  of  longer  duration  than  a  week,  a 
tremulous  tongue,  facies,  a  pulse  below  120,  an  enlarged  spleen,  and 
a  few  roseolar  spots,  will  aid  in  the  diagnosis. 

The  diagnosis  of  typhoid  fever  must,  therefore,  be  confirmed  by 
the  Widal  reaction,  except  in  a  small  percentage  of  cases.  The  pres- 
ence of  roseola,  enlarged  spleen,  facies,  tremulous  tongue,  diarrhoea, 
and  continued  remittent  fever  are  the  clinical  symptoms  which  should 
lead  the  physician  to  apply  the  test. 

Prognosis. — The  prognosis  of  typhoid  fever  in  infancy  and  child- 
hood is,  as  a  rule,  good.  The  mortality  varies  with  the  severity  of 
the  infection  and  the  character  of  the  epidemic.  If  the  infection  is 
severe,  the  complications  will  militate  against  recovery.  Henoch,  in 
375  cases  had  a  mortality  of  14  per  cent. ;  Blackader,  in  100  cases 
lost  only  1 ;  Crozer  Grifiith  had  a  mortality  of  3, per  cent. 

It  is  commonly  supposed,  and  some  authors  lay  stress  on  the  fact, 
that  the  mortality  of  typhoid  fever  in  children  is  lower  than  in  the 
adult,  and  therefore  the  prognosis  is  better.  This  simple  statement 
does  not  give  us  any  idea  as  to  the  true  mortality  of  typhoid  fever  in 
children.  Some  authors  place  the  mortality  in  this  disease  as  low 
as  4  or  5  per  cent.  This  may  be  true  of  some  statistics  in  certain 
epidemics.  In  a  series  of  222  hospital  cases  of  my  own  of  typhoid 
fever  in  children,  ranging  from  thirteen  months  to  thirteen  years,  the 
average  mortality  was  7.6  per  cent.  This  would  about  express  the 
average  mortality  of  typhoid  fever  in  children  when  epidemics  of 
varying  severity  are  taken  into  account. 

In  this  same  material  the  mortality  in  one  year  was  only  4  per 
cent.,  and  in  another  as  high  as  16  per  cent.  It  will  be  seen  from 
this  that  hospital  cases,  from  which  all  statistics  are  drawn,  show  that 
the  mortality  of  typhoid  fever  in  infants  and  children  is  much  the 
same  as  in  the  adult  cases. 

In  222  cases  of  typhoid  fever  there  were  12  per  cent,  of  relapses. 
In  this  we  include  only  those  cases  in  which  there  was  a  true  relapse 
— that  is,  an  average  normal  temperature  for  at  least  eight  days  pre- 
ceding the  relapse.  The  average  duration  of  the  relapse  was  eleven 
days.     The  mortality  in  cases  where  there  had  been  a  relapse  was  nil. 

Treatment. — The  treatment  of  mild  cases  of  typhoid  fever  is  purely 
symptomatic.  There  is  little  need  for  the  administration  of  medi- 
cines. On  the  other  hand,  the  severer  cases  are  difficult  to  manage. 
This  is  especially  true  in  the  treatment  of  children,  to  whom  it  is  not 


TYPHOID    FEVER.  333 

always  possible  to  apply  methods  adopted  with  the  adult.  In  cases 
in  which  delirium  is  present  night  and  day  bromides  in  large  doses 
are  efficacious.  With  older  children  they  may  prove  useless,  and 
morphine  may  then  be  necessary  to  meet  the  exigencies  of  the  case. 

In  the  vast  majority  of  cases  milk,  milk  soups,  and  cereal  soups 
form  the  basis  of  the  diet.  If  there  is  progressive  emaciation,  one, 
two,  or  three  raw  eggs  should  be  added  to  the  milk  daily.  In  other 
cases  malted  milk,  junket,  whey,  or  matzoon  may  vary  the  diet.  It 
is  well  in  protracted  cases  not  to  wait  too  long  for  a  complete  drop  of 
temperature  before  resorting  to  other  foods  than  milk.  This  is  espe- 
cially true  of  cases  extending  over  a  period  of  seven  or  eight  weeks, 
in  which  there  is  always  a  rise  of  temperature  of  half  a  degree  or  a 
degree  above  the  normal  for  a  few  days,  with  a  drop  again  to  the 
normal  or  subnormal.  In  these  cases  there  is  a  form  of  inanition 
fever,  post-typhoidal  in  nature.  Solid  food  should  not  be  withheld 
too  long  lest  the  emaciation  become  extreme.  After  the  fifth  week 
we  may  in  most  cases  allow  the  patient  gruels  containing  cereals. 
After  the  temperature  has  fallen  to  the  normal  and  remained  there 
for  four  or  five  days,  it  is  safe  to  return  gradually  to  a  full  diet.  It 
is  doubtful  if  relapses  occur  as  a  result  of  too  early  feeding  if  this 
method  is  followed.  In  comatose  states  resort  may  be  had  to  forced 
feeding. 

Alcohol. — Alcohol  is  not  needed  in  mild  cases.  It  is  given  in 
cases  in  which  the  pulse  is  weak  and  the  temperature  high.  Delirium 
is  no  contraindication  to  its  use,  as  it  is  in  other  affections. 

Heart. — The  heart  is  stimulated  by  digitalis,  strychnine,  or  cam- 
phor. If  the  heart  has  shown  slight  dilatation  with  a  murmur  devel- 
oping in  the  course  of  the  disease,  the  patient  should  not  be  allowed 
out  of  bed  too  soon  for  fear  that  unfavorable  symptoms  may  result. 

Hydrotherapy. — The  temperature  is  controlled  by  hydrotherapy. 
The  patient  is  placed  in  a  bath  at  100°  F.  (3Y.7°  C),  and  the  tem- 
perature of  the  water  gradually  reduced  to  85°  F.  (29.4°  C).  With 
older  children  the  temperature  may  be  lowered  still  further.  Chil- 
dren do  not  bear  the  classical  Brand  bath  treatment  well.  The 
plunge  bath  is  given  three  or  four  times  daily  whenever  the  tempera- 
ture is  103°  F.  (39.4°  C.)  or  more.  Should  the  child  struggle  very 
much  against  the  administration  of  the  bath,  it  is  wiser  to  forego  it 
and  substitute  sponging.  If  the  sponging  is  not  followed  by  good 
reaction,  the  use  of  water  should  be  abandoned.  In  cases  of  delirium 
a  bath  once  or  twice  daily  at  105°  F.  (40.5°  C.)  has  a  quieting  effect. 
The  utmost  gentleness  must  be  observed  while  the  patient  is  in  the 
bath  lest  some  latent  abdominal  complication  may  be  aggravated. 

Hemorrhages. — Hemorrhages  from  the  bowel  are  not  frequent  in 
children.     They  may  occur  early  or  late  in  the  disease.     In  the  latter 


334  TEE  SPECIFIC  INFECTIOUS  DISEASES. 

case  they  must  be  differentiated  from  hemorrhage  due  to  enterocolitis 
of  a  post-tjphoidal  character.  In  hemorrhage  due  to  typhoidal  ulcer 
an  ice-bag  is  applied  to  the  abdomen,  and  small  doses  of  opium,  pref- 
erably the  deodorized  tincture,  are  administered  to  control  peristalsis. 
Ergot  and  digitalis  are  given  internally  in  order  to  contract  the  blood- 
vessels if  possible.  Enemata  should  not  be  given.  If  the  hemor- 
rhage becomes  excessive,  it  is  proper  to  give  hot  saline  enemata,  and 
to  infuse  normal  saline  solution  under  the  skin  or  into  the  veins. 

Enteritis. — Enteritis  of  an  ulcerative  or  pseudomembranous  char- 
acter occurring  as  a  complication  of  typhoid  fever  is  treated  in  the 
same  manner  as  the  primary  affection  of  the  same  nature. 

Perforation. — Perforation  should  be  treated  on  surgical  princi- 
ples. As  with  adults,  those  perforations  v^hich  occur  late  in  the  dis- 
ease, when  the  patient  is  in  an  exhausted  and  emaciated  condition, 
give  a  less  favorable  prognosis  than  those  which  occur  early.  The 
surgical  treatment  will  be  more  successful  the  sooner  the  diagnosis  is 
established,  for  in  those  cases  in  which  peritonitis  has  advanced  to  a 
marked  degree  the  prognosis  is  fatal.  The  success  of  surgical  treat- 
ment will  also  depend  largely  on  the  fact  as  to  whether  the  perfora- 
tion is  single  or  multiple.  In  one  of  my  cases  it  was  demonstrated 
at  operation  that  no  less  than  three  ulcers  had  perforated,  and  there 
were  as  many  more  on  the  point  of  perforation,  so  that  in  this  case 
simple  sewing  up  of  the  ulcerated  parts  could  scarcely  have  suc- 
ceeded in  saving  the  patient,  for  in  this  very  case  a  perforation  after 
operation  caused  the  death  of  the  patient.  In  such  cases  the  treat- 
ment of  multiple  perforations  is  a  problem  for  the  surgeon.  In  cases 
of  doubt  an  exploratory  operation  for  the  presence  or  absence  of  a 
perforation  is  justifiable  and  even  called  for. 

Constipation. — In  most  cases  of  typhoid  fever  an  enema  will 
remove  accumulated  fi"eces  from  the  lower  bowel.  Enemata  are  not 
given  unless  indicated.  If  the  bowel  contents  are  streaked  with 
blood,  enemata  should  be  discontinued.  In  cases  in  which  there  is 
a  slight  rise  of  temperature  during  convalescence  without  apparent 
cause,  grains  v  (0.3)  hydrarg.  cum  creta  should  be  given.  Tympa- 
nites is  treated  as  in  the  adult  subject.  The  evacuations  should  be 
mixed  with  an  equal  volume  of  a  solution  of  carbolic  acid  (1:20) 
as  soon  as  passed.  The  hands  of  the  nurse  should  be  thoroughly 
cleansed  after  each  movement.  The  patient's  hands  are  cleansed 
daily,  in  order  to  avoid  auto-infection. 

MALARIAL    FEVER. 

(Paludism;  Malaria;  IntermiUcnt  Fever.) 

Malarial  fever  is  an  acute  infections  disease  due  to  the  inocula- 
tion of  the  individual  with  the  Plasmodium  malaria?.     It  is  common 


MALARIAL   FEVEE.  335 

in  infants  and  young  children,  and  is  believed  to  occur  in  utero. 
Crandall  has  reported  a  case  in  which  symptoms  developed  eighteen 
hours  after  birth,  and  in  v^hich  the  plasmodium  was  found  in  the 
blood  of  the  infant.  Those  who,  like  Moncorvo  of  Brazil,  have  oppor- 
tunities to  observe  malarial  fever  in  young  infants  and  children,  find 
the  greatest  frequency  under  two  years.  The  author  has  not  met 
paludism  as  frequently  in  the  nursing  infant  as  in  older  children. 
The  reason  for  this  must  lie  in  the  fact  that  young  infants  are  more 
protected  from  infection  with  veils,  etc.,  than  older  children.  One 
attack  does  not  confer  immunity  to  subsequent  attacks ;  on  the  con- 
trary, infants  and  children  once  the  subject  of  paludal  poisoning  seem 
particularly  liable  to  reinfection  and  relapses. 

The  period  of  incubation  varies  from  a  few  hours  to  weeks.  In 
the  tertian  type  it  is  believed  to  be  from  seven  to  fourteen  days.  In 
one  of  my  cases  the  first  chill  appeared  eleven  days  after  the  patient 
had  left  the  malarious  district. 

Etiology. — The  essential  cause  of  malarial  fever  is  the  same  in 
infants  and  children  as  in  the  adult.  It  is  an  inoculation  fever,  and 
is  conveyed  to  the  human  subject  by  a  certain  species  of  mosquito 
(Anopheles).  The  poison  exists  in  the  neighborhood  of  swamps  and 
stagnant  waters. 

The  Parasite. — The  plasmodium  or  protozoa  of  malaria  circulates 
in  the  blood  of  infants  and  children,  undergoing  its  cycle  and  sporu- 
lation  in  the  same  manner  as  in  the  adult.  In  one  series  of  cases 
in  infants  and  children  that  I  studied,  the  tertian  was  the  most  preva- 
lent form  of  parasite.  These  cases  occurred  in  ISTew  York  City  and 
its  vicinity.  This  has  been  the  experience  of  other  IsTew  York  City 
observers.  One  may  assume  that  the  blood  will,  as  a  rule,  contain 
the  parasite  prevalent  in  a  given  locality.  Several  forms  of  parasites 
may  exist  in  the  blood  of  the  same  child,  or  there  may  be  several 
generations  of  the  same  plasmodium.  These  may  mature  at  different 
times,  giving  various  types  of  fever  in  the  same  subject.  In  a  tertian 
case,  the  fever  may  thus  become  quotidian,  a  second  set  of  parasites 
causing  a  distinct  chill  and  fever  (paroxysm)  on  the  day  when  the 
first  generation  is  quiescent.  We  may  have,  as  Mannaberg  and 
others  pointed  out,  simple  and  double  tertians  and  quartans.  But  no 
combination  of  quartan  parasites  can  simulate  the  simple  tertian  type. 
I  have  seen  very  few  cases  of  quartan  in  children.  They  are  uncom- 
mon in  ISTew  York  City,  but  I  have  seen  preparations  of  the  quartan 
type  which  were  found  in  the  blood  of  children  in  the  Southern  States. 
As  in  adults,  tertian  paroxysms  may  occur  every  day,  caused  by  two 
sets  of  parasites  which  mature  at  about  the  same  time  daily,  or  one 
set  matures  at  a  different  hour  than  the  set  of  the  following  day.  In 
such  a  case  paroxysms  would  occur  at  the  same  hour  only  every  other 


336  THE  SPECIFIC  INFECTIOUS  DISEASES. 

day.  Many  children  have  a  distinct  severe  paroxysm  only  every 
other  day,  but  on  the  intervening  day  a  careful  examination  v^ill 
detect  a  very  low  fever.  This  is  probably  due  to  a  set  of  parasites 
which  mature  without  producing  marked  chill  or  fever  (abortive). 

The  Blood.- — In  recent  tertian  I  have  found  young  spores  in 
abundance  in  the  blood  a  few  hours  after  the  chill.  In  some  speci- 
mens the  spores  were  free.  Between  paroxysms  in  tertian  cases  the 
blood  contains  colorless  oval  plasmodia — the  fully  developed  body — 
leucocytes  having  rods  and  pigment-granules  and  rarely,  small  round 
forms  with  flagellse  (Koplik).  In  stained  specimens  (methyl-blue) 
young  native  forms  are  found  in  all  stages  up  to  fully  developed 
protozoa.  The  red  blood-cell  containing  the  parasite  is  distinctly 
enlarged.  I  have  found  in  the  stained  specimen  as  in  the  unstained 
ones,  the  sporula  in  free  groups,  bodies  with  flagellse,  and  erythro- 
cytes with  stained  granules.  The  half-moons  are  also  found  in 
chronic  cases.  The  blood  contains  free  granules,  and  peculiar  shrunken, 
brassy-colored,  red  blood-cells.  Monti  found  the  specific  gravity  of 
the  blood  to  be  increased. 

Morljid.  Anatomy. — Post-mortem  examinations  in  cases  of  malarial 
fever  in  infants  and  children  are  exceedingly  rare.  Opportunity  may 
be  afforded  when  death  occurs  as  the  result  of  accident  or  of  some 
other  disease.  Monti  states  that  in  fatal  cases  the  spleen  is  enlarged ; 
the  capsule  is  tense,  and  in  places  shows  rupture.  The  pulp  is  dark 
red  owing  to  pigment  deposit  (melanin).  Old  spleens  show  a  dis- 
appearance of  melanin  and  a  deposit  of  yellow  ochre  pigment  along 
the  trabeculse.  In  chronic  cases  the  connective  tissue  is  increased, 
the  liver  is  enlarged,  and  there  is  atrophy  of  the  liver-cells.  The 
parasites  are  found  in  the  blood.  The  endothelium  of  the  blood- 
vessels contains  yellow  and  brown  pigment.  In  exceptional  cases 
there  are  melanin  deposits.  In  acute  cases  the  bone-marrow  is  the 
seat  of  melanin  deposit;  later  this  disappears,  and  the  marrow  is 
found  to  be  yellow  and  fatty.  The  brain  cortex  in  severe  cases  shows 
pigment  deposit ;  sometimes  there  are  thromboses  and  hemorrhages. 

Symptoms. — Children  living  in  malarious  districts  do  not  always 
manifest  malarial  poisoning  by  having  paroxysms  of  chills  and  fever. 
The  disease  is  masked  under  the  form  of  a  progressive  anaemia,  with 
accompanying  enlargement  of  the  spleen.  These  patients  may  de- 
velop symptoms  in  from  a  few  days  to  a  few  weeks  after  leaving  the 
malarious  region. 

The  onset  of  a  paroxysm  is  usually  marked  by  the  appearance 
of  chills.  In  young  infants  a  distinct  chill  is  not  always  present. 
They  become  cold  and  blue  at  a  certain  time  each  day.  In  older 
children  the  paroxysm  is  indicated  by  headache  and  a  feeling  of 
lassitude,  which  comes  on  at  a  certain  time  each  day,  or  by  a  dis- 


MALARIAL    FEVER.  337 

tinct  chill.  In  exceptional  cases  eclampsia  or  vomiting  may  usher 
in  a  paroxysm.  In  other  cases  there  is  no  eclampsia,  but  the  hands 
become  cold,  there  is  a  feeling  of  faintness,  and  the  child  complains 
of  being  ill.  Meanwhile  there  is  a  rise  of  temperature,  during  which 
there  are  muscular  tremors  of  the  extremities  and  a  peculiar  upward 
rolling  of  the  eyes,  indicating  an  impending  convulsive  seizure.  The 
chill  may  occur  during  sleep.  In  one  case  the  mother  noticed  that 
the  child  (three  years  of  age)  became  pale  during  sleep,  the  hands 
and  extremities  became  cool,  and  the  pulse  rapid.  The  febrile  move- 
ment following  the  chill  may  be  very  slight,  scarcely  half  a  degree 
above  the  normal.  In  such  cases  the  chill  is  not  marked  or  is  scarcely 
noticeable.  This  occurs  in  double  tertian,  in  which  one  paroxysm  is 
abortive.  In  most  cases  the  fever  is  very  high  at  first — so  high  that 
it  is  characteristic.  A  temperature  of  106.5°  F.  (41.3°  C.)  is  not 
uncommon,  and  is  well  borne.  As  a  rule,  the  fever  has  a  distinctly 
intermittent  type.  The  temperature  may  rise  after  the  initial  chill 
and  remain  high  for  days,  and  then  fall  to  the  normal.  In  the  simple 
form  the  fever  lasts  from  four  to  twelve  hours,  and  is  followed  by  a 
critical  perspiration,  during  which  the  temperature  rapidly  falls  to 
the  normal.  In  some  cases  the  children  appear  free  from  symptoms 
in  the  interval  between  the  paroxysms.  Others  suffer  from  headaches 
and  a  feeling  of  lassitude,  and  in  infants  there  are  gastric  and  intes- 
tinal disturbances.  In  protracted  cases  a  distinct  anaemia  develops, 
with  progressive  enlargement  of  the  spleen,  l^ieuralgia  of  the  periph- 
eral nerves  has  been  noted  in  older  children. 

During  a  paroxysm  Monti  noted  polyuria,  which  persisted  until 
the  following  day. 

The  spleen  enlarges  rapidly,  and  in  a  short  time  may  be  felt  as 
low  down  as  the  umbilicus.  I  have  found  the  spleen  markedly 
enlarged;  in  one  case  the  organ  was  not  palpable  below  the  ribs, 
although  a  slight  enlargement  could  be  detected  on  percussion. 

The  liver  may  be  enlarged  in  chronic  cases. 

In  subacute  forms  chills  are  not  present,  but  there  is  an  irregular 
febrile  movement,  with  progressive  ansemia  and  splenic  enlargement. 

Repeated  Attacks  or  Relapses. — Children,  as  well  as  adults,  may 
have  repeated  attacks  of  malarial  fever.  As  a  rule,  however,  these 
so-called  independent  attacks  in  children  are  relapses,  due  either  to 
inefficient  treatment  or  to  the  development  of  a  new  series  of  para- 
sites. Infants  may  have  relapses.  I  have  treated  such  eases  until 
all  anaemia  and  signs  of  active  malarial  poisoning  had  disappeared, 
and  then  administered  arsenic  for  months,  only  to  find  a  return  of  the 
symptoms  after  an  interval  of  months. 

Diagnosis.- — -The  diagnosis  of  malarial  fever  is  based  upon  an 
examination   of   the   blood.      If   a    child    suffers    from   pronounced 

22 


338  THE  SPECIFIC  INFECTIOUS  DISEASES. 

ansemia,  malaise,  pains  in  the  limbs,  and  enlarged  spleen  the  blood 
should  be  carefully  examined.  Expert  knowledge  is  always  necessary 
for  a  definite  diagnosis.  It  is  surprising  to  note  the  large  number  of 
cases  beginning  with  chills  and  presenting  an  intermittent  fever 
curve  and  enlarged  spleen,  diagnosed  as  malarious,  in  which  parasites 
cannot  be  detected  in  the  blood.  Many  septic  and  inflammatory  proc- 
esses in  infants  and  children  simulate  malaria.  Rachitis,  syphilis, 
gastro-enteric  catarrh,  otitis,  pneumonia,  typhoid  fever  with  relapses, 
have  all  been  mistaken  for  malarial  fever.  The  diagnosis  rests  on  an 
examination  of  the  blood  in  all  cases  in  which  chills  and  fever  or  any 
of  the  symptoms  described  coexist  with  enlargement  of  the  spleen. 

Quinine  should  not  be  administered  until  the  blood  has  been  very 
carefully  examined.  In  other  words,  malaria  should  be  diagnosed 
or  excluded  before  resorting  to  this  remedy,  which  was  formerly  much 
in  vogue  as  a  diagnostic  test.  Its  use  before  diagnosis  can  only  result 
in  uncertainty,  since  there  are  rises  in  temperature,  not  due  to  the 
paludism,  which  may  be  influenced  by  quinine.  A  very  high  tem- 
perature of  an  intermittent  type,  in  connection  with  other  physical 
signs,  should  cause  the  physician  to  consider  the  possibility  of  paludal 
poisoning. 

I  have  not  seen  cases  of  the  pernicious  type.  They  occur  in  the 
Southern  States. 

Acker  has  published  2  cases  of  malarial  fever  in  children,  in 
which  there  were  the  initial  cerebral  symptoms  of  coma  and  con- 
vulsions. Coma  in  one  case  came  on  in  paroxysms.  In  the  interval 
the  child  was  rational.  The  sestivo-autumnal  parasite  (pernicious) 
was  found  in  the  blood. 

Prognosis. — The  prognosis  of  malarial  fever  in  ISTew  York  City  is 
very  good.  With  proper  treatment  the  patient  should  recover.  I 
have  never  met  a  fatal  case.  They  occur  in  districts  in  which  the 
pernicious  type  of  the  disease  is  prevalent. 

Treatment. — If  pjossible,  the  patient  should  be  removed  from  the 
malarious  district.  The  remedies  employed  in  all  cases  are  quinine 
and  arsenic,  or  their  derivatives. 

According  to  Golgi,  quinine  should  be  given  before  the  paroxysm, 
and  also  in  the  intervals.  The  action  of  the  drug  is  exerted  directly 
upon  the  plasmodium.  At  this  time  segmentation  of  the  parasite 
takes  place  in  the  blood,  and  most  of  the  young  parasites  are  free  in 
the  plasma.  They  then  respond  most  quickly  to  quinine.  Large 
doses  should  be  given  to  infants  and  children,  in  order  that  the  infec- 
tion may  be  destroyed  quickly  and  completely.  The  soluble  bisul- 
phate  and  muriate  are  suitable  preparations.  To  an  infant  under 
one  year  of  age  grains  ij  (0.1)  are  given  in  a  dose,  repeated  three 
times  a  day,  the  last  dose  being  given  from  three  to  five  hours  before 


INFLUENZA.  339 

a  paroxysm.  To  children  between  two  and  five  years  of  age  grains 
iij  to  V  (0.2  to  0.3)  are  giyen  in  the  same  manner.  Some  infants 
take  quinine  readily  when  it  is  suspended  in  powder  form  in  milk 
or  water ;  others  are  given  a  piece  of  chocolate,  and  when  the  surface 
of  the  mouth  is  coated  with  the  candy  the  drug  is  administered. 
Euquinine  is  a  preparation  tasteless  and  odorless,  and  is  readily  taken 
by  children.  It  has  the  disadvantage  of  causing  vomiting  in  some 
children.  The  dose  is  the  same  as  that  of  quinine.  The  syrup  of 
yerba  santa  is  a  good  menstruum.  In  cases  in  which  children  cannot 
take  quinine  by  mouth,  Jacobi  advises  giving  it  per  rectum,  dissolv- 
ing the  drug  in  a  solution  of  tartaric  acid.  In  the  severe  form  of 
pernicious  malarial  fever  of  the  tropics  quinine  is  given  by  the  hypo- 
dermic method. 

Infants-  and  children  with  chronic  or  subacute  forms  of  malaria 
are  likely  to  be  constipated.  Under  these  conditions  I  have  found 
calomel  more  efficient  in  clearing  the  g-ut  than  castor  oil. 

After  the  quinine  treatment  has  been  continued  for  some  time  the 
spleen  will  be  observed  to  diminish  in  size  and  the  paroxysms  to  dis- 
appear. If  the  anaemia  persists,  it  is  well,  after  diminishing  the 
frequency  of  the  dosage  of  quinine,  to  combine  it  with  small  doses 
of  Fowler's  solution.  The  arsenic  must  occasionally  be  temporarily 
discontinued,  or  the  functions  of  the  stomach  will  become  deranged. 
Warburg's  tincture  does  not  seem  to  be  very  efficacious  with  children 
under  five  years  of  age,  nor  with  older  children,  unless  given  in  very 
large  doses.  Children  do  not  develop  cinchonism  as  quickly  as  adults, 
and  the  quinine  may  therefore  be  continued  for  a  long  time.  Treat- 
ment should  not  be  suspended  until  the  spleen  is  no  longer  palpable 
and  the  angemia  has  disappeared.  Quinine  should  then  be  continued 
in  small  doses  at  regular  intervals. 

The  preparations  of  cinchona,  such  as  cinchonidia,  cinchonidin, 
chinidin,  etc.,  are  not  reliable.  The  following  is  Baccelli's  formula 
for  the  subcutaneous  use  of  quinine  in  pernicious  intermittent  fever: 

Quinin.   nuiriat 15  grs.  (1.0). 

Natrium  chlorat 1  gr.  (0.06). 

Aq.  destillat 3iiss     (10.0). 

INFLUENZA. 

{La  Grippe;  Acute  Catarrhal  Fever.) 

Influenza  is  a  specific  infectious  disease  chiefly  afi^ecting  the 
mucous  membranes.  It  is  highly  contagious,  although  all  individuals 
exposed  do  not  contract  the  disease.  It  occurs  in  the  form  of  pan- 
demics in  which  whole  communities  are  affected.  This  pandemic 
form  occurs  less  frequently  in  children  than  in  adults,  and  is  of 


340  TEE  SPECIFIC  INFECTIOUS  DISEASES. 

interest  to  the  physician  only  when  an  epidemic  prevails.  The 
endemic  form  of  influenza  affects  children  more  frequently  than 
adults,  and  is  the  form  which  will  be  described,  although  in  its  symp- 
toms it  closely  resembles  the  epidemic  form.  The  endemic  form  may 
occur  at  any  season  of  the  year.  In  large  cities  influenza  is  endemic, 
and  appears  to  be  more  prevalent  after  rapid  changes  from  lower  to 
higher  temperatures.  Rapid  fluctuations  in  the  humidity  of  the 
atmosphere  in  winter  also  favor  the  development  of  the  germs  of  this 
disease.  In  l^ew  York  City,  midwinter  and  spring  are  the  seasons 
when  outbreaks  of  this  affection  occur.  Influenza  sometimes  becomes 
epidemic  in  hospital  services.  I  have  recently  had  this  experience 
and  Holt  has  published  a  study  of  influenza  pneumonia  in  institutions. 
Age. — Influenza  may  affect  the  newly  born  infant,  A  case  of 
this  kind  is  reported  by  Townsend  in  the  Transactions  of  the  Amer- 
ican Pediatric  Society.  The  disease  is  most  frequent  between  the 
ages  of  six  months  and  five  years.  The  younger  the  child,  the  more 
severe  the  affection. 

Mode  of  Infection. — Individuals  are  infected  by  coming  into  con- 
tact (contact  infection)  with  others  suffering  with  the  disease.  The 
germ  is  contained  in  the  sputum  and  the  nasal  secretions;  therefore 
poorly  ventilated  rooms  and  public  conveyances  and  institutional  con- 
ditions favor  the  transmission  of  the  disease.  Parents  may  transmit 
it  to  their  children  in  the  act  of  kissing,  and  wet-nurses  who  have  la 
grippe  are  likely  to  infect  the  infant  at  the  breast. 

Etiology. — The  epidemic  form  of  influenza  has  been  studied  by 
Pf eiffer  and  Kitasato.  Pf eiffer  isolated  a  bacillus  from  the  bronchial 
mucous  membrane,  trachea,  and  lungs.  This  bacillus,  which  is  now 
believed  to  be  the  essential  cause  of  epidemic  influenza,  is  exceed- 
ingly small,  and  two  or  three  times  as  long  as  it  is  broad.  It  has 
rounded  extremities,  occurs  in  pairs  and  chains,  does  not  stain  by 
Gram's  method,  and  in  influenza,  pneumonia,  and  encephalitis  is 
found  in  enormous  numbers  in  the  lungs.  It  is  called  the  Bacillus 
influenzae.  It  is  still  an  open  question  whether  it  occurs  in  the  blood. 
Although  this  bacillus  has  been  found  in  sporadic  cases  of  endemic 
influenza,  competent  observers,  Luzzato  among  the  latest,  have  found 
that  in  a  large  number  of  endemic  cases  of  influenza  the  Pfeiffer 
bacillus  is  absent.  In  its  place  is  found  the  Frankel  diplococcus. 
This  is  thought  to  be  the  essential  cause  of  an  important  group  of 
cases  of  endemic  and  sporadic  influenza  in  children — the  so-called 
pneumococcus  grippe.  Predisposing  elements  in  the  etiology  of 
endemic  influenza  are  exposure  to  cold  and  a  diminution  of  the 
strength  of  the  individual.  One  attack  does  not  protect  the  indi- 
vidnal  from  subsequent  attacks. 

Incubation. — Influenza  is  believed  to  have  an  incubation  period 


INFLUENZA.  341 

of  from  twelve  hours  to  three  days.  Endemic  influenza  occurs  fre- 
quently in  large  cities  and  at  times  local  epidemics  of  the  disease 
are  seen. 

Morbid  Anatomy. — Inasmuch  as  influenza  is  rarely  fatal,  the 
pathological  anatomy  is  imperfectly  formulated.  In  fatal  cases  a 
general  inflammatory  condition  of  the  mucous  membrane  of  the  nasal 
passages  and  of  the  larynx  and  trachea,  is  found.  The  surface  of 
the  lining  membrane  of  the  bronchi  is  reddened,  covered  with  muco- 
pus,  and  the  membrane  itself  is  infiltrated  with  small  round  cells. 
There  may  be  a  diffuse  inflammation  of  the  smaller  bronchi,  with 
peribronchitis  and  inflammatory  reaction.  Areas  of  bronchopneu- 
monia or  lobar  pneumonia  are  found  in  the  lungs.  The  heart  is 
dilated  and  the  seat  of  myocarditis.  There  may  be  endocarditis  and 
the  kidneys  may  present  an  acute  nephritis.  The  pleurae  are  inflamed, 
and  there  may  be  serous  or  serofibrinous  pleurisy  or  empyema. 

Among  the  other  lesions  are  those  due  to  the  complications,  otitis, 
meningitis,  inflammation  of  the  gastro-intestinal  tract,  and  cerebro- 
spinal meningitis. 

Symptoms. — It  has  been  customary  to  divide  the  symptomatology 
of  endemic  influenza  as  it  occurs  in  children  into  clinical  forms. 
According  to  my  experience,  there  is  no  sharp  dividing-line  between 
the  various  forms  of  endemic  influenza  as  seen  in  children.  The 
gastro-intestinal,  nervous,  and  pneumonic  forms  are  frequently  pres- 
ent in  the  same  patient.  Endemic  grippe  as  it  occurs  in  children  in 
ISTew  York  City  will  be  described,  the  epidemic  or  pandemic  form 
being  ignored. 

The  most  frequent  form  is  the  catarrhal  of  an  acute  and  even 
subacute  type.  The  infant  or  child  may  at  the  outset  have  a  chill. 
Most  frequently  there  is  vomiting,  and  also  fever,  and  pains  in  the 
head  and  limbs.  There  is  a  coryza,  and  in  many  cases  a  croupy, 
barking  cough.  The  eyes  are  injected,  the  face  is  red  and  flushed, 
and  the  child  presents  an  appearance  resembling  that  of  the  first 
stage  of  measles.  The  mucous  membrane  of  the  throat  is  deeply 
injected  and  the  tonsils  inflamed  and  enlarged. 

The  temperature  is  elevated ;  in  fact,  at  the  outset  it  is  as  high  in 
this  disease  as  in  malarial  fever,  106.5°  F.  (41.3°  C).  The  cough 
is  sometimes  incessant.  The  irritation  in  the  throat  is  extreme,  and 
vomiting  after  the  coughing  paroxysm  may  lead  the  physician  to 
believe  that  he  is  dealing  with  whooping-cough.  In  young  infants 
these  symptoms  may  last  for  a  day  or  two,  during  which  the  move- 
ments may  become  green  and  even  diarrhoeal.  This  diarrhoea  is 
sometimes  so  severe  as  to  be  a  prominent  feature  of  the  disease.  The 
prostration  both  in  infants  and  children  is  marked.  After  two  or 
three  days  the  catarrhal  condition  of  the  upper  air-passages  subsides. 


342 


THE  SPECIFIC  INFECTIOUS  DISEASES. 


Fig.  50. 


and  the  patient  develops  symptoms  of  an  acute  broncMtis  of  a  severe 
t}73e.  These  forms  of  grippal  bronchitis  have  at  the  outset  a  high 
febrile  curve,  and  a  fever  persisting  for  days.  The  bronchitis  affects 
the  smallest  bronchi.  They  may  develop  a  bronchopneumonia  in 
small  areas. 

In  other  cases  the  bronchitis  passes  suddenly  into  a  pneumonia 
without  a  preceding  chill.  The  pneumonia  of  la  grippe  may  be 
lobular  or  lobar  in  type.  In  the  vast  majority  of  cases  the  pneu- 
monia is  of  the  pneumococcus  variety. 
Esj)ecially  severe  are  the  cases  of  grippe 
which  are  ushered  in  with  a  chill,  high 
fever  and  cerebral  symptoms,  such  as 
sopor,  delirium,  and  rigidity  of  the  neck 
muscles.  In  many  of  these  cases  exami- 
nation of  the  chest  reveals  pneumonia. 
These  cases  are  not  so  common  among 
infants  as  among  older  children. 

Cases  in  which  there  is  a  cerebro- 
spinal infection  in  no  way  differ  in  symp- 
tomatology from  cases  of  cerebrospinal 
meningitis  due  to  the  meningococcus  or 
the  pneumococcus.  The  endemic  grip- 
pal forms  of  cerebrospinal  meningitis 
may  be  caused  by  the  influenza  bacillus 
(Sanger).  I  have  had  six  cases  of  cere- 
brospinal meningitis  caused  by  the  bacil- 
lus of  influenza.  The  diagnosis  was  con- 
firmed by  lumbar  puncture  and  the  culti- 
vation of  the  bacillus  on  media.  The 
child  at  first  complains  of  fatigue,  and 
has  a  tendency  to  sleepiness,  cries  out  and 
starts  in  its  sleep,  and  suffers  from  intense  headache.  After  a  time 
vomiting  with  rigidity  of  the  muscles  of  the  neck  sets  in.  These 
symptoms  increase  in  intensity,  sopor  finally  setting  in  with  all  the 
symptoms  of  a  cerebrospinal  meniugitis.  These  cerebral  cases  are  rare. 
A  common  form  of  grippal  attack  is  that  in  which  all  the  symp- 
toms of  nasopharyngeal  inflammation  are  present.  There  is  also  mild 
bronchitis  of  the  larger  tubes.  The  temperature  may  fall  to  the 
normal  in  the  morning  or  toward  noon,  but  toward  evening  it  rises 
from  one-half  a  degree  to  three  degrees  above  the  normal.  The 
child  plays  in  the  afebrile  intervals.  It  may  awake  from  sleep  in 
a  peevish,  irritable  mood,  or  may  start  in  its  sleep.  These  symp- 
toms may  continue  for  a  week  or  longer.  In  many  of  these  cases 
there  is  serous  or.  purulent  otitis  media,  or  there  may  even  be  a 


M 

E 

M 

E 

M 

E 

^    101° 

of 

X 

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UJ 

i  100° 
< 

tr 

Q- 

S 

UJ 

DAY  OF 
DISEASE 

PULSE 
RES  P. 
DATE 

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106'^ 

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106 

X 

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Feb.  2 

3 

4 

Endemic  influenza  with  bron- 
chitis in  an  infant  seven  months 
of  age. 


INFLUENZA. 


;43 


mastoid  inflammation  from  the  outset.  In  other  cases  the  patient 
has  an  intermittent  or  remittent  fever.  The  fever,  if  a  continued 
one,  has  morning  or  evening  remissions.  Examination  of  the  heart 
may  reveal  an  acute  endocarditis,  although  marked  symptoms  of  car- 
diac involvement  may  be  absent. 

Symptoms  referable  to  the  kidney  have  received  little  attention 
in  text-books.     In  endemic  grippe  there  is  almost  always  a  slight 


Fig. 

51. 

DAY 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

104° 
103° 

hJ 

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1     103 
< 

111 

UJ 

a. 

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UJ 

1- 

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99° 

, 
S 

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DAY  OF 
DISEASE 

1 

2 

3 

4 

5 

6 

7 

8 

PULSE 

X 

103 

/^^ 

^^ 

136'^ 

150'^ 

W^ 

120 

RESP. 

X 

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DATE 

Feb.  2 

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4 

6 

6 

1 

8 

9 

Endemic  influenza,  lobar  pneumonia  of  the  lower  lobe  of  the  right  lung.     Child 
two  and  one-half  years  of  age. 


trace  of  albumin  in  the  urine,  which,  as  a  rule,  disappears  at  con- 
valescence. Occasionally,  there  is  a  true  nephritis,  with  casts,  de- 
creased secretion,  and  blood.  Such  cases  have  been  described  by 
Freeman.  Of  grave  import  are  the  cases  of  nephritis  in  endemic 
grippe  which  at  first  show  a  trace  of  albumin  and  a  few  hyaline, 


344  TEE  SPECIFIC  IXFECTIOrS  DISEASES. 

epithelial,  and  blood-casts,  witli  a  very  small  (microscopic)  amount 
of  blood  in  the  urine.  The  urine  is  normal  in  amount.  The  con- 
dition is  revealed  only  by  the  microscope.  CEdema  is  absent.  The 
child  is  at  first  pale,  but  this  pallor  disappears  later.  The  trace  of 
albiunin  in  the  urine,  hoTvever,  with  a  few  casts  and  blood-cells,  per- 
sists for  months.  These  cases  may  be  mistaken  for  '"  cyclic "  albu- 
minuria. They  are  really  nephritis  of  an  insidious  character  follow- 
ing endemic  grippe. 

I  have  seen  cases  of  endemic  grippe  complicated  with  swelling 
of  the  parotid  and  submaxillary  glands  and  of  the  lymph-nodes  of 
the  neck. 

Otitis  media  is  a  common  complication  of  influenza  in  winter  and 
spring.  Such  cases  may  run  their  course  without  complication  or 
result  in  mastoiditis  or  sinus  thrombosis. 

Duration. — The  duration  of  endemic  grippe  is  from  two  or  three 
days  to  as  many  weeks.  I  have  seen  cases  present  a  temperature- 
curve  for  three  weeks,  but  have  not  met  the  cases  of  protracted  dura- 
tion, with  or  without  fever,  described  by  Filatow.  and  would  regard 
such  cases  as  peculiar  to  the  country  of  that  author. 

Prognosis. — The  prognosis  of  endemic  grippe  is  favorable.  If 
complications  supervene,  it  varies  with  their  nature. 

Diagnosis. — The  diagnosis  presents  no  difficulties.  In  some  cases 
the  nervous  symptoms  may  cause  the  physician  to  suspect  meningitis 
when  pneumonia  is  present.  A  careful  physical  examination  will 
dispel  the  doubt.  Meningitis  and  pneumonia  may  be  present  in  the 
same  case.  Otitis  may  supervene  without  the  presence  of  marked 
symptoms  referable  to  the  ear.  An  aural  examination  should  be 
made  in  all  cases  in  which  fever  persists  and  physical  examination  of 
the  lungs  and  other  organs  fails  to  reveal  abnormal  conditions. 

Treatment. — The  treatment  of  influenza  is  simple.  At  the  outset 
in  the  milder  cases  small  doses  of  quinine  are  administered,  to  control 
the  headache,  restlessness,  and  fever.  For  the  angina  small  doses  of 
ferric  chloride  are  given  to  infants  every  one  to  three  hours.  In 
older  children,  the  throat  is,  in  addition,  sprayed  two  or  three  times 
daily  with  salt  solution  or  a  solution  of  boric  acid.  The  fever  is 
treated  by  sponging;  packing  or  baths  are  rarely  necessary.  The 
bowels  of  infants  are  washed  out  with  high  enemata  if  diarrhoea 
sets  in,  and  milk  food  is  temporarily  suspended.  Pneumonia,  if 
present,  is  treated  as  outlined  in  the  section  on  that  disease.  Otitis 
should  be  treated  by  early  incision  of  the  drum-membrane,  as  even 
cases  in  which  no  pus,  but  only  serum,  is  present  are  relieved  by  this 
procedure.  With  older  children  the  use  of  phenacetin  alone  or  in 
combination  with  monobromate  of  camphor  is  permissible  if  the  head- 
ache and  pains  in  the  limbs  are  very  troublesome.     A  grain  of  each 


GLANDULAR    FEVER.  345 

may  be  given  once  or  twice  daily  for  a  short  time.  The  prostration 
is  best  combated  by  the  use  of  strychnine  alone  or  combined  with 
caffeine.  Alcohol  is  not  well  borne  in  these  cases,  since  it  is  likely 
to  cause  gastro-intestinal  symptoms. 

In  those  cases  in  which  there  are  meningeal  symptoms  lumbar 
puncture  should  be  performed  to  determine  the  presence  of  meningitis. 

GLANDULAR    FEVER. 

(Pfeiffer.) 

Glandular  fever  is  a  form  of  infection  which  manifests  itself  by 
an  enlargement  of  the  lymph-nodes  of  the  neck,  with  accompanying 
enlargement  of  the  liver  and  spleen,  and  an  initial  period  of  fever. 
It  occurs  from  the  second  to  the  eighth  year  of  life,  but  may  occur  in 
infancy.  During  an  extensive  epidemic  J.  P.  West  observed  it  in 
the  nursing  infant. 

Etiology. — The  etiology  is  obscure.  This  disease  is  a  species  of 
infection  or  toxaemia.  In  some  cases  (West)  there  has  been  diarrhoea, 
in  others  constipation,  and  in  most  cases  a  slight  injection  of  the  naso- 
pharynx. It  is  possible  that  the  infectious  agent  gains  access  to  the 
lymph-channels  through  the  gut  or  nasopharynx.  This  would  account 
for  the  involvement  of  the  mesenteric  glands,  as  observed  by  Pfeiffer, 
and  for  the  infection  of  the  nodes  of  the  neck  through  the  thoracic  duct. 

Symptoms. — After  slight  malaise,  or  even  without  prodromata, 
children  are  attacked  with  fever,  restlessness,  headache,  vomiting,  and 
pains  in  the  limbs.  After  a  few  hours  of  these  premonitory  symp- 
toms, swelling  of  the  cervical  glands  on  one  or  both  sides  is  noticed. 
These  glandular  swellings  extend  from  beneath  the  body  of  the  jaw 
along  and  beneath  the  upper  third  of  the  sterno-mastoid  muscle.  The 
lymph-nodes  beneath  the  muscle  are  also  affected.  After  one  or  two 
days  these  glands  or  nodes  not  only  increase  in  size,  but  nodes  at  the 
back  of  the  neck  and  in  the  supraclavicular  region  are  also  affected. 
In  the  cases  recorded  by  West  the  axillary  and  inguinal  lymph-nodes 
were  also  involved.  The  temperature  at  first  ranges  from  102°  to 
104°  F.  (38.8°  to  40°  C),  but  in  from  twenty-four  to  forty-eight 
hours  it  may  fall  by  crisis.  There  is  a  slight  redness  of  the  pharynx 
or  the  color  of  the  mucous  membrane  may  be  normal.  There  is  pain 
on  deglutition,  and  there  may  be  a  slight  cough,  but  no  distinct  pul- 
monary affection.  In  both  Pfeiffer's  and  West's  cases  the  liver  and 
spleen  were  enlarged.  In  the  cases  of  Starck,  Rauchfuss,  and  Pro- 
tossow  these  enlargements  were  not  always  present. 

Lymph-nodes. — The  lymph-nodes  may  enlarge  to  the  size  of  a 
pigeon's  egg.  The  redness  of  the  pharynx  is  disproportionate  to  the 
enlargement  of  the  nodes  (Rauchfuss),  so  that  it  is  hardly  permissible 


346  THE  SPECIFIC  INFECTIOUS  DISEASES. 

to  speak  of  an  anginal  lymphadenitis,  as  in  scarlet  fever.  In  both 
Starck's  and  West's  cases  there  was  enlargement  of  the  nodes,  which 
were  not  painful,  but  sensitive  to  pressure.  The  swelling  of  the 
carotid  lymph-nodes  began,  as  a  rule,  after  a  few  hours,  was  in  most 
cases  first  visible  on  the  left  side  of  the  neck,  and  reached  its  height 
from  the  second  to  the  fourth  day.  The  glands  on  the  opposite  side 
of  the  neck  then  became  affected.  The  swelling  rarely  continues 
unilateral.  It  is  uniform,  as  thick  as  an  index-finger  (West),  and 
is  composed  of  several  nodes.  There  is  a  stiffness  of  the  neck  and 
also  a  sensation  of  choking.  Suppuration  is  absent.  There  is  in 
all  cases  a  tenderness  of  the  abdomen  about  the  umbilicus,  which,  in 
Pfeiffer's  opinion,  indicates  an  infection  of  the  mesenteric  nodes. 
West  found  the  mesenteric  nodes  enlarged  in  37  cases. 

In  ISTew  York  there  have  occurred  every  year  in  the  winter  months 
a  large  number  of  cases  in  which  the  symptoms  were  limited  to  en- 
largement of  the  lymph-nodes  on  either  side  of  the  neck  at  the  angle 
of  the  jaw.  Sometimes  the  nodes  in  the  axilla  were  also  enlarged. 
There  was  a  high  febrile  movement  for  days  and  weeks.  These 
cases  resolved,  leaving  no  further  evidences  of  infection.  I  have 
regarded  such  cases  as  those  of  glandular  fever. 

Diagnosis. — The  disease  is  readily  differentiated  from  mumps. 
In  some  epidemics  the  submaxillary  glands  were  involved,  but  never 
the  parotid.  The  appearance  of  the  swelling  of  the  lymph-nodes  fi^rst 
on  one  side,  and  then  on  the  other  side  of  the  neck  is  characteristic, 
and  should  be  differentiated  from  the  glandular  swellings  occurring 
with  grippal  affections  or  pneumonia.  Heubner  has  reported  cases 
in  which  there  was  a  complicating  nephritis. 

Duration. — The  fever  disappears  after  a  few  hours  or  may  last 
two  or  three  days.  It  may  recur  later.  The  glandular  swellings, 
however,  increase  or  persist  nine  to  twenty-seven  days,  the  average 
duration  being  sixteen  days  (West,  Eauchfuss). 

Treatment. — As  the  affection  has  a  tendency  to  spontaneous  recov- 
ery, the  treatment  is  purely  symptomatic. 

MENINGITIS. 

Classification  of  the  Different  Forms  of  Meningitis.- — The  simplest 
classification  is  that  which  divides  meningitis  into  the  primary  and 
secondary  forms.  The  primary  form  includes  cerebrospinal  menin- 
gitis of  the  epidemic  type,  or  cerebrospinal  fever,  as  also  the  sporadic 
forms  of  this  disease,  and,  as  a  separate  entity,  the  pneumococcus 
meningitis.  In  the  secondary  forms  we  have  the  tuberculous  and 
pneumococcus  meningitis,  the  latter  being  secondary  to  pneumonia, 
endocarditis,  or  injury  of  the  cranial  bones.     Third,  there  are  the 


MENINGITIS.  347 

pyogenic  forms  of  meningitis,  due  to  staphylococci,  streptococci  or 
secondary  either  to  the  disease  of  the  cranium  or  local  infections. 
Fourth,  there  are  the  forms  of  meningitis  secondary  to  typhoid  fever, 
influenza,  colon  bacillus,  diphtheria,  gonorrhoea,  syphilis,  anthrax, 
actinomycosis.  Fifth,  in  a  separate  rubric  there  is  the  so-called 
serous  meningitis,  which  is  recognized  as  a  secondary  form  of  dis- 
ease, due  probably  to  streptococci  or  pyogenic  organisms.  It  will 
be  seen  that  this  classification  recognizes  both  the  sporadic  and  the 
epidemic  forms  of  the  cerebrospinal  fever  as  the  same  disease  due  to 
the  same  essential  cause,  the  meningococcus  of  Weichselbaum. 

Barlow  and  Gee  divide  simple  meningitis  in  infants  and  children, 
as  to  locality,  first,  into  the  vertical  form,  which  is  a  leptomeningitis, 
and  affects  the  vertex  of  the  cerebrum,  sometimes  spreading  toward 
the  base,  and  often  involving  the  cord ;  and  in  the  second  class  they 
include  the  so-called  postero-basic  forms  of  meningitis,  in  which  the 
exudate  is  confined  principally  to  the  posterior  part  of  the  base  of 
the  brain. 

All  forms  of  meningitis  may  be  cerebrospinal  as  to  distribution 
and  it  should  be  understood  that  the  term  cerebrospinal  meningitis 
has  been  retained  and  when  used  refers  more  particularly  to  the  men- 
ingococcus form. 

In  constructing  this  section  the  author  has  utilized  114  cases  of 
meningitis  occurring  in  his  hospital  service.  They  were  divided  into 
the  following  groups:  68  were  cases  of  the  cerebrospinal  form  of 
meningitis  of  the  epidemic  type.  Of  the  remaining  cases,  35  were 
tuberculous  forms  of  meningitis,  1  case  a  so-called  staphylococcus 
meningitis,  1  case  a  primary  pneumococcus  meningitis,  3  cases  strep- 
tococcus meningitis,  and  in  6  cases  a  bacillus  corresponding  to  the 
influenza  bacillus  in  cultural  characteristics. 

The  author  will  first  consider  cerebrospinal  meningitis  of  the  epi- 
demic, and  sporadic  type,  and  then  will  consider  the  so-called  vertical 
meningitis  and  postero-basic  meningitis  of  Barlow  and  Gee,  serous 
meningitis,  and  finally  tuberculous  meningitis. 

Cerebrospinal  Meningitis  (Cerebrospinal  Fever;  Spotted  Fever; 
Meningococcus  meningitis;  Petechial  Fever;  Malignant  Purpuric 
Fever) .- — Cerebrospinal  meningitis  is  an  acute  infectious  disease,  the 
characteristic  lesion  of  which  is  an  exudative  inflammation  of  the  pia 
mater  of  the  brain  and  spinal  cord.  It  occurs  in  epidemics,  but  may 
occur  sporadically. 

Etiology. — Cerebrospinal  meningitis,  both  in  its  epidemic  and 
sporadic  forms,  is  due  to  an  infection  by  the  Diplococcus  meningitidis 
intracellularis  of  Leichtenstern,  Weichselbaum,  and  Jager.  This 
micro-organism  is  a  diplococcus  reminding  one  strongly  in  its  form 
of  the  gonococcus.     It  is  decolorized  by  the  Gram  stain.     It  is  found 


348  TBE  SPECIFIC  INFECTIOUS  DISEASES. 

not  only  in  the  body  of  the  pus-cell — hence  its  name — but  in  the 
exudate  also  outside  of  the  pus-cell. 

Though  the  epidemic  form  of  cerebrospinal  meningitis  is  caused 
in  the  vast  majority  of  cases  by  this  micro-organism,  there  is  another 
group  of  cases  of  the  cerebrospinal  type  which  is  caused  by  the  Diplo- 
coccus  pneumoniae.  This  latter  class  of  cases  has  been  described  by 
Xetter,  Foa,  and  Bordoni-Uffreduzzi.  These  cases  may  occur  epi- 
demically also,  but  are  generally  seen  in  combination  with  lobar  or 
bronchopneumonia,  or  as  a  complication  of  otitis  media.  The  form 
of  affection  discussed  in  this  section  is  rather  the  sporadic  and  epi- 
demic type  of  cerebrospinal  meningitis  caused  by  the  intracellular 
diplococcus  above  mentioned.  In  the  epidemics  of  this  disease  so  far 
observed,  it  is  not  unusual  for  several  members  of  a  family  to  be 
attacked.  The  rule,  however,  is  the  contrary.  The  cases  in  an  epi- 
demic number  several  hundreds,  the  last  epidemic  in  ISTew  York 
amounting  to  somewhat  over  1000  cases. 

The  disease  seems  to  have  no  marked  tendency  to  spread.  In 
large  cities  the  epidemics  occur  in  the  spring  of  the  year ;  and,  after 
the  epidemic  has  run  its  course,  sporadic  cases  are  observed  in  the  fall 
and  winter  months. 

Mode  of  Infection.— It  has  been  a  matter  of  great  speculation  as 
to  how  the  infection  is  conveyed  from  person  to  person  in  this  disease, 
if  such  does  occur;  and  also  as  to  the  manner  in  which  the  micro- 
organism— the  intracellular  diplococcus — gains  access  to  the  circula- 
tion. Cases  are  observed  here  and  there,  and  I  have  seen  two  such 
cases  in  the  last  epidemic,  in  which  the  disease  is  complicated  by 
pneumonia,  the  meningitis  and  the  pneumonia  both  being  due  to  the 
intracellular  diplococcus.  These  cases,  however,  are  exceptional.  It 
has  been  supposed  that  the  micro-organism  gains  access  to  the  circu- 
lation through  lymph-spaces  in  the  mucous  membrane  of  the  nose  and 
conjunctivae. 

I  have  published  one  case  in  which  the  Diplococcus  intracellularis 
was  found  in  the  secretion  of  the  conjunctiva  in  a  child  suffering 
with  the  disease,  in  whom  the  meningitis  had  been  preceded  by  a  con- 
junctivitis. Wright  has  published  a  case  in  which  the  intracellular 
diplococcus  was  found  in  the  nasal  secretions  of  a  person  suffering 
from  influenza  symptoms,  mild  headache,  fever,  and  constitutional 
disturbances,  which  might  very  well  have  been  a  mild  form  of  cere- 
brospinal meningitis.  A  micrococcus,  so-called  Micrococcus  catarrh- 
alis,  is  found  in  the  normal  secretions  of  the  nose,  and  it  has  been 
mistaken  time  and  again  for  the  Diplococcus  intracellularis. 

It  has  been  intimated  that  the  infection  may  gain  access  to  the 
circulation  through  the  respiratory  organs.  However  these  facts  may 
be,  they  do  not  definitely  establish  how  the  infectious  material  gains 


PLATE  XVI 


Cover-glass  Stain  of  the  Sedimented  Fluid  Obtained  by  Lumbar 
Puncture  in  Epidemic  Cerebrospinal  Meningitis. 

Polymorphonuelear  cytology;  -vacuolization  of  the  leukocytes  and  lympho- 
cytes; peculiar  conformation  of  the  nuclei  in  cells;  large  cells  resembling  lym- 
phocytes; Diplocoecus  meningitidis  in  the  cell  body  of  the  leukocytes  and  also 
outside  of  the  cell  bodies  in  smaller  numbers 


Jf' 


PLATE  XVII 


-— >^i  -'' 


"W' 


K 


,r?s», 


1.  /• 

« 

;>-:;r"-^^i.^^__ 

f  / 

i=.i.^ 

.-<* 


y'^  %•- 

'   .J5 

V" 

/•a".  .  _!i^-  .  .7'-:.;-, 

'  ''■^''■'': 

'          Kr. 

4 


Section  of  the  Spinal  Cord,  showing  the  Exudate  on  the  Surface, 
More  Marked  Posteriori  y  and  Involving  the  Anterior  and  Posterior 
Nerve  Roots.  Epidemic  cerebrospinal  meningitis  in  an  adult; 
death  on  the  fifth  day  of  the  disease. 


PLATE  XVII I 


f  nk, 


The    Exudate  of  the   Early  Stage  and  Inflanimatory  Reaction 

in  the  Pia  Mater. 

This  shows:  Swelling  cells  of  the  pia;  fibrin  in  the  exudate;  the  leu.koeytie 
invasion;  new  connective-tissue  cells;  nuclear  division;  large  cells  containing 
three  or  more  leukocytes  described  by  Councilnian,  Mallory,  and  ^A/■  right. 


MENINGITIS.  349 

access  to  the  circulation,  or  whether  the  disease  is  conveyed  from 
person  to  person. 

Occurrence.- — Cerebrospinal  meningitis  is  distinctly  a  disease  of 
young  people.  Eotch  reports  a  case  in  an  infant  six  days  old.  The 
youngest  case  of  the  epidemic  type  seen  by  me  occurred  in  an  infant 
ten  weeks  old.  Of  111  cases  reported  by  Councilman,  29  occurred 
in  infants  and  children.  Of  a  series  of  70  cases  of  cerebrospinal 
meningitis  reported  by  me,  47  per  cent,  were  under  two  years  of 
age;  the  youngest  was  four  months  of  age,  and  61  per  cent,  of  the 
cases  were  under  four  years  of  age.  The  oldest  child  in  my  hos- 
pital service  was  fourteen  years  of  age.  Thus  the  average  age  was 
two  years. 

Morbid  Anatomy. — ^In  certain  sporadic  cases  of  cerebrospinal 
meningitis  of  the  epidemic  type  the  clinical  symptoms  may  have  been 
very  marked,  and  yet  post-mortem  examination  fails  to  reveal  any 
gross  macroscopical  lesions  of  the  brain  and  j^ia  mater.  They  appear 
to  be  normal.  Under  the  microscope,  however,  a  slight  infiltration 
of  the  pia  with  pus  and  fibrin  and  a  new  growth  of  cells  is  seen.  In 
other  cases  there  is  an  extensive  infiltration  of  the  pia  with  serum, 
fibrin,  and  pus.  The  exudation  is  especially  profuse  at  the  base  of 
the  brain  and  on  the  posterior  surface  of  the  cord,  more  especially  in 
those  cases  which  will  hereafter  be  described  as  postero-basic  menin- 
gitis. The  ventricles  of  the  brain  may  be  markedly  distended  with 
serum  and  even  pus.  Among  the  associated  lesions  found  are  sub- 
serous punctate  hemorrhages  of  the  endocardium;  ecchymoses  and 
petechise  of  the  skin,  hyaline  and  granular  degeneration  of  muscle, 
multiple  abscesses  of  the  skin,  suppuration  of  the  joints,  parenchy- 
matous degeneration  of  the  heart,  liver,  and  kidneys,  and  swelling 
of  the  lymph-nodes  and  spleen.  In  all  the  epidemic  cases  of  the  type 
referred  to  in  this  section  the  Diplococcus  intracellularis  is  found  in 
the  exudate  of  the  pia  mater  and  cortex  of  the  brain  and  in  the  fluid 
of  the  ventricles. 

Symptoms. — There  are  certain  types  of  cerebrospinal  meningitis 
which  are  seen  both  in  the  epidemic  and  sporadic  forms  of  the  disease. 
The  malignant  types  are  seen  rather  in  the  epidemic  forms ;  whereas 
the  milder  types  are  seen  in  the  sporadic  cases.  Clinically,  therefore, 
we  may  divide  all  cases  of  epidemic  cerebrospinal  meningitis  into 
three  forms :  The  first  form  is  the  malig-nant  type  of  the  disease,  in 
which  the  children,  in  previous  good  health,  are  attacked  and  die 
within  twenty-four  or  thirty-six  hours  of  the  onset  of  the  disease. 

The  following  case,  one  of  the  first  of  the  epidemic  of  1904,  is  a 
characteristic  example  of  this  type:  An  infant  twelve  months  old, 
nursed  at  the  breast;  perfectly  formed,  large,  healthy,  bright  child, 
never  previously  affected  by  any  illness,  nursing,  and  bowels  normal. 


350  TSE  SPECIFIC  INFECTIOUS  DISEASES. 

On  the  morning  of  the  onset  of  the  illness  the  child  appeared  drowsy 
and  stupid,  refused  the  breast,  vomited  once,  hut  was  not  feverish. 
In  the  evening  the  infant  was  still  drowsy  and  listless ;  the  tempera- 
ture rose  to  103°  F. ;  pulse  110  and  weak.  There  was  no  peculiarity 
about  the  eyes,  no  stiffness  of  the  muscles  of  the  neck  or  body.  Early 
on  the  morning  of  the  next  day  the  child  awoke  with  a  cry,  and  the 
mother  discovered  red  spots  on  the  cheeks;  the  face  was  slightly 
swollen;  the  eyes  had  a  staring  expression,  and  the  child  was  appar- 
ently blind.  A  few  hours  later  the  entire  face,  hands,  and  body  were 
covered  with  blotches  of  an  ecchymotic  character.  The  tissues  of 
the  extremities  seemed  to  be  hard  to  the  touch  and  swollen.  The 
buttocks  and  body  appeared  as  if  the  child  had  been  beaten.  Petechise 
and  ecchymosis  involved  the  whole  surface  of  the  body.  At  this  time 
the  temperature  was  101°  F.,  pulse  very  weak,  scarcely  perceptible 
at  the  wrist,  the  lips  blue,  the  reflexes  abolished.  There  was  no 
rigidity  of  the  muscles  of  the  neck.  There  was  no  Kernig  symptom. 
The  pupils  were  uneven  and  did  not  react ;  there  was  a  slight  con- 
junctivitis. The  breathing  was  weak  and  catchy.  Death  super- 
vened within  a  few  hours.  These  cases  are  not  unusual  in  epidemics, 
and  here  and  there  sporadic  cases  occur  of  this  type. 

Another  type  of  case  is  the  more  common  form  of  the  disease. 
A  child  in  aj^parent  health  will  suddenly  complain  of  headache,  fever, 
and  begin  to  vomit.  There  may  be  a  chill.  The  fever  is  generally 
high,  the  pulse  rapid.  The  headache  is  very  severe  and  is  a  constant 
leading  symptom.  There  is  also  intense  pain  at  the  back  of  the  neck, 
extending  down  the  back.  The  child  is  irritable  and  restless,  tossing 
about,  intolerant  of  light  and  sound.  Any  interference  and  touch  on 
examination  of  the  surface  of  the  body  causes  pain ;  in  other  words, 
there  is  hyperesthesia.  After  a  few  hours  rigidity  of  the  muscles 
at  the  back  of  the  neck  appears,  and  this  rigidity  may  increase  to 
opisthotonos ;  in  some  cases  on  the  second  day  there  may  be  repeated 
convulsions.  When  the  disease  is  completely  inaugurated  the  child 
lies  in  bed  in  a  characteristic  attitude,  the  lower  extremities  flexed, 
the  arms  flexed,  the  head  slightly  retracted.  The  children,  for  the 
most  part,  lie  on  the  side. 

With  the  full  onset  of  symptoms  in  some  epidemics  petechise 
appear  with  ecchymoses  over  the  whole  surface.  These  petechise 
vary  in  size  from  a  pin-head  to  large  blotches  resembling  hemorrhages 
due  to  traumatism.  Ecchymoses  are  seen  especially  on  the  extensor 
surfaces  of  the  lower  extremities.  The  patients  complain  of  constant 
headache,  some  are  very  restless,  delirium  sets  in;  the  delirium  may 
be  of  a  mild  or  muttering  type.  In  some  cases  there  is  no  sleep,  the 
patients  toss  here  and  there  in  the  bed,  and  complain  of  constant 
pain  in  the  head.     The  bowels  may  be  constipated ;  in  some  cases 


PLATE   XIX 


Convexity  of  the  Brain..     LLJiuomic  cerebrospinal  meningitis  >Arith 
death  on  the  fifth  day  of  the  disease.     Purulent  exudate. 


Fia   2 


Lateral  View  of  the  Brain  in  the  Same  Case. 


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MENINGITIS.  351 

there  is  diarrhcea.  The  urine  may  contain  evidences  of  a  nephritis. 
In  other  cases  no  such  evidence  is  present.  The  amount  of  urme 
passed  in  some  cases  may  be  enormous;  in  other  v^ords,  there  is 
polyuria.  The  spleen  may  be  enlarged.  The  type  of  case  just  de- 
scribed corresponds  to  the  mass  of  cases  seen  in  an  epidemic. 

A  third  type  of  this  disease  is  more  puzzling  in  its  character ;  it 
affects  infants  and  young  children  in  apparent  health.  Infants  and 
children  are  noticed  to  have  a  constant  rise  of  temperature;  there 
may  be  vomiting;  there  is  restlessness;  if  nursing,  they  refuse  the 
breast.  The  fever  after  a  few  days  takes  an  intermittent  course, 
mounting  as  high  as  104°  and  105°  F.  at  certain  times  of  the  day; 
falling  to  the  normal  or  subnormal  at  others.  In  the  intervals  of 
freedom  from  temperature  the  children  or  infants  v^ill  play,  and 
when  the  temperature  rises  they  complain  of  headache  (if  old  enough), 
become  drowsy  and  irritable,  refuse  nourishment,  and  develop  symp- 
toms which  point  toward  meningeal  inflammation,  such  as  the  Kernig 
symptom,  rigidity  of  the  back  of  the  neck.  In  these  cases  the  typical 
symptoms  of  meningitis  are  not  always  present.  Delirium  may  not 
be  constant  or  may  not  extend  over  the  twenty-four  hours.  The 
rigidity  of  the  neck  may  not  be  very  marked,  especially  in  young 
infants.  The  Kernig  symptom  in  children,  especially  below  two 
years  of  age,  may  not  be  evident.  The  most  characteristic  feature 
of  these  cases,  it  seems,  is  the  prolonged  temperature  of  an  intermit- 
tent type,  closely  resembling  malarial  fever.  In  fact,  many  of  these 
cases  have  been  mistaken  for  malaria. 

There  is  a  fourth  type  of  case,  which  will  be  described  under  the 
heading  of  Postero-basic  Meningitis,  which  is  observed  not  only  spo- 
radically, as  has  been  remarked  by  Still,  but  also  in  epidemics. 

Mode  of  Onset. — In  all  the  cases  that  I  have  had  an  opportunity 
to  observe  in  my  hospital  and  private  practice,  and  in  which  the  diag- 
nosis was  confirmed  by  lumbar  puncture,  the  main  characteristic  of 
the  disease  was  its  sudden  onset.  In  only  a  small  percentage  of  cases 
was  there  a  doubtful  history  of  sudden  onset.  In  this  respect  the 
disease  differs  markedly  from  other  forms  of  meningitis,  especially 
those  of  the  tuberculous  type,  in  which  the  invasion  is  slow  and 
insidious.  From  a  study  of  the  symptoms  the  onset  may  simulate 
an  attack  of  gastro-enteritis  in  some  children. 

Cerebral  Symptoms. — If  the  fontanelle  is  not  closed  there  is  dis- 
tinct bulging  or  tenseness,  even  in  the  early  stages  of  the  disease, 
certainly  before  the  fifth  day.  The  patients  suffer  from  delirium  or 
coma,  and  in  the  milder  cases  headache  is  the  principal  symptom, 
and  periods  of  consciousness  alternate  with  those  of  stupor.  Rigidity 
of  the  neck,  either  slight  or  marked,  is  present  at  one  time  or  another 
in  all  cases,  and  opisthotonos  is  present  in  about  TO  per  cent,  of  the 
cases  (Plate  XX.). 


352  THE  SPECIFIC  INFECTIOUS  DISEASES. 

According  to  Osier,  neck  rigidity  or  opisthotonos  was  not  present 
in  tlie  adult  form  of  primary  pneiimococcus  meningitis.  In  one  case, 
however,  of  my  own,  of  primary  pneumococcus  meningitis  in  a  child, 
neck  rigidity  was  present.  There  is  hypersesthesia  of  the  surface, 
and  the  patients  cry  out  if  the  bed  is  jarred  or  the  skin  touched. 
In  some  cases  there  are  recurrent  rigors  and  convulsions,  either  uni- 
lateral or  general.  There  may  be  facial  paralysis  and  hemiplegia 
in  the  early  or  the  later  stages  of  the  disease. 

Reflexes. — In  the  majority  of  cases  of  epidemic  cerebrospinal 
meningitis  the  patellar  reflex  is  present  in  the  early  stages  of  the 
disease,  but  it  may  disappear  in  the  rapidly  fatal  or  moribund  cases. 
The  so-called  tache  cerebrale  of  Trousseau  is  obtained  in  all  cases. 

BabinsJci  Reflex. — Babinski,  a  French  neurologist,  described  the 
extension  of  the  great  toe  and  separation  of  the  other  toes  on  irrita- 
tion of  the  plantar  surface  of  the  foot  as  a  characteristic  sign  of  dis- 
ease of  the  pyramidal  tracts  or  the  lateral  columns  of  the  cord.  In 
epidemics  of  cerebrospinal  meningitis  this  phenomenon  is  obtained  in 
only  a  small  percentage  of  cases,  in  contradistinction  to  what  is  noted 
in  the  tuberculous  form  of  meningitis,  in  which  it  is  common,  being 
obtained  in  6  of  26  of  my  cases  of  tuberculous  meningitis.  The 
Babinski  reflex  is  of  very  little  value  in  children  and  infants  below 
two  years  of  age,  for  a  phenomenon  closely  resembling  it  is  obtained 
in  perfectly  normal  individuals  at  this  age  (Fig.  83). 

Kernig  Symptom. — The  Kernig  symptom — that  is,  an  inability 
to  extend  the  leg  on  the  thigh  when  the  latter  is  flexed  on  the  trunk — 
is  obtained  at  one  time  or  another  in  all  cases  of  cerebrospinal  menin- 
gitis. In  children  below  two  years  of  age,  however,  this  sign  must 
be  accepted  with  caution  because  of  the  natural  tendency  in  infants 
and  children  of  this  age  to  contraction  of  the  lower  extremities,  a 
variety  of  normal  myotonia  (Fig.  52).  On  the  other  hand,  in  cases 
of  so-called  cerebral  symptoms  complicating  pneumonia  and  typhoid 
fever,  the  Kernig  phenomenon  may  also  be  apparent,  so  that,  although 
it  is  present  in  all  cases  of  meningitis,  it  is  not  pathognomonic  of  the 
disease.  It  may  be  absent  in  eases  of  the  malignant  type  in  which 
there  are  collapse  symptoms. 

Hyperwsthesia. — In  the  majority  of  cases  of  cerebrospinal  menin- 
gitis, after  the  symptoms  are  fully  established,  the  patients  are  irri- 
table, refuse  to  be  comforted,  start  at  the  slightest  sound,  lie  mostly 
on  the  side,  the  arms  and  lower  extremities  flexed,  the  body  taking 
a  crouching  position.  Any  attempt  to  disturb  the  patients  is  met 
with  resistance.  The  amount  of  hypersesthesia  varies  not  only  in 
the  different  epidemics,  but  in  different  types  of  the  disease,  but  it  is 
present  in  most  cases,  thus  being  in  marked  contrast  to  what  is  seen 
in  the  tuberculous  form  of  meningitis,  in  which  the  children  lie  in  a 


MENINGITIS.  353 

stuporous  condition,  do  not  notice  their  surroundings,  cannot  be 
roused,  and  are  not  as  irritable  as  in  the  epidemic  cerebrospinal  form. 

MacEwens  Sign.  — •  MacEwen  has  shown  that  in  children,  in 
various  forms  of  meningitis,  percussion  of  the  skull  over  the  anterior 
horn  of  the  ventricles  will  give  a  tympanitic  note  if  the  head  is  so  held 
that  the  frontal  or  parietal  bone  may  be  percussed  over  the  anterior 
horn  of  the  ventricle.  The  patient  is  placed  in  the  sitting  posture, 
with  the  head  inclined  to  one  side,  and  percussion  of  the  inferior 
frontal  or  parietal  bone  is  carried  out. 

The  MacEwen  sign  is  obtained  in  those  cases  of  the  cerebrospinal 
meningitis  in  which  there  is  an  accumulation  of  fluid  in  the  ventri- 
cles, and  was  absent  in  only  2  cases  of  13  studied  with  a  view  to 

Fig.  52. 


Kernig  symptom  in  a  case  of  cerebrospinal  meningitis   of  the   epidemic  type.     Female, 

nine  years  of  age. 

obtaining  this  sign.  It  is  more  common  in  the  tuberculous  forms 
of  meningitis. 

Facial  Pares^is. — In  epidemic  cerebrospinal  meningitis  facial  pa- 
ralysis may  occur  in  the  very  severe  cases  at  the  outset  of  the  disease, 
especially  if  the  base  of  the  brain  is  involved. 

Paralysis. — There  may  be  paralysis  not  only  of  the  facial  mus- 
cles, but  of  the  extremities  on  one  or  the  other  side,  either  at  the  outset 
of  the  disease  or  toward  the  close. 

Eyes. — There  may  be  an  initial  conjunctivitis,  keratitis,  strabis- 
mus, contraction,  dilatation,  or  inequality  of  the  pupils ;  neuritis  of 

23 


354  THE  SPECIFIC  INFECTIOUS  DISEASES. 

varying  grades  of  the  disk ;  atrophy,  and  finally  purulent  choroiditis. 
There  is  no  appreciable  impairment  of  vision  in  some  cases.  In  a 
fonr-months-old  baby  paralysis  of  the  orbital  muscles  of  one  side 
appeared  early  in  the  disease.'  A  peculiar  phenomenon  has  been 
observed  by  me  and  described  by  others  referable  to  the  pupils :  If 
an  attempt  is  made  to  bend  the  head  forward  as  the  patient  lies  in 
bed  unconscious,  the  pupils  will  be  observed  to  dilate  (mydriasis). 

Contrary  to  the  generally  accepted  opinion,  we  have  found  that 
expert  examination  of  the  fundus  of  the  eye  in  cases  of  cerebrospinal 
meningitis  of  the  epidemic  type  revealed  few  changes  in  the  optic 
pupilla  in  the  majority  of  cases.  In  some  cases  there  was  dilatation 
of  the  veins,  or  congestion  without  neuritis.  In  only  one  case  was 
there  descending  neuritis.  This  corresponds  very  closely  to  what 
Barlow  and  Gee  found  to  be  true  both  of  the  vertical  and  postero- 
basic  forms  of  meningitis.  In  a  group  of  26  cases  of  meningitis  of 
the  tuberculous  variety,  however,  examined  by  an  expert  ophthalmol- 
ogist, some  change  was  found  in  the  fundus  in  fully  77  per  cent,  of 
the  cases.  This  change  consisted  either  of  an  optic  neuritis  or  papil- 
litis, or  the  presence  of  tubercles  in  the  choroid. 

Blood.— The  leucocyte  count  in  cases  of  cerebrospinal  meningitis 
of  the  epidemic  type  ranges  from  20,000  to  55,000  to  the  cubic  milli- 
metre in  55  per  cent,  of  the  cases.  There  are  cases,  however,  with  a 
low  leucocyte  count  of  11,00.0  to  12,000  to  the  cubic  millimetre. 
This  corresponds  very  closely  to  what  was  found  by  Osier  to  be  true 
of  the  adult  cases.  In  tuberculous  forms  of  meningitis,  however,  of 
infants  and  children,  in  40  per  cent,  of  the  cases  there  is  a  leucocyte 
count  of  20,000  to  25,000  to  the  cubic  millimetre,  and  in  60  per  cent, 
of  the  cases  the  leucocyte  count  is  below  20,000  to  the  cubic  milli- 
metre.    Rarely,  however,  does  the  leucocyte  count  exceed  24.000. 

In  the  fatal  cases,  in  Avhich  the  lumbar  puncture  may  yield  a  fluid 
markedly  purulent,  the  leucocyte  count  may  mount  from  35,000  to 
55,000  to  the  cubic  millimetre.  On  the  other  hand,  a  fatal  case  with 
fluid  obtained  by  lumbar  puncture  might  show  a  leucocyte  count  not 
exceeding  23,200. 

Cases  which  have  recovered  may  show  in  the  course  of  the  disease 
a  leucocyte  count  of  14,000  to  28,000  to  the  cubic  millimetre,  and 
they  may  have  mounted  as  high  as  45,000.  It  cannot,  therefore,  be 
said  that  a  prognosis  as  to  recovery  or  fatal  issue  can  be  made  from 
the  leucocyte  count  alone  in  cerebrospinal  meningitis. 

Pulse. — The  pulse  in  cerebrospinal  meningitis,  as  a  rule,  is  rapid 
and  irregular;  but  there  are  periods  in  which  the  pulse  is  slow,  some- 
times 80  or  even  lower.  This  is  not  as  common,  however,  as  the 
rapid  pulse. 

Respirations. — The  respirations,  as  a  rule,  are  shallow,  increased 


MENINGITIS. 


855 


in  frequency,  and  irregular  in  rhythm.  In  a  few  cases  there  may 
be  Cheyne-Stokes  respiration.  In  other  cases  Cheyne-Stokes  respira- 
tion is  not  seen  in  the  whole  course  of  the  disease ;  as  the  fatal  issue 
approaches,  the  respirations  may  cease  before  the  heart  ceases  to  beat. 
In  the  terminal  stages  the  respirations  sometimes  fall  to  10  a  minute, 
and  the  pulse  to  50,  indicating  the  onset  of  general  paralysis. 

Temperature. — There  is  no  curve  of  temperature  which  is  dis- 
tinctive of  cerebrospinal  meningitis.  It  may  be  said,  however,  that 
the  temperature  in  many  cases  is  of  the  intermittent  variety,  and  for 
this  reason  these  cases  are  frequently  mistaken  for  malaria.  In  the 
intermittent  type  of  temperature  the  remissions  are  very  gTeat,  some- 
times ranging  eight  degrees  in  twenty-four  hours;  that  is,  a  tempera- 
ture which  has  been  high  will  in  a  few  hours  fall  to  the  subnormal  to 
rise  again.     This  is  not  uncommon  and  may  extend  over  weeks.     On 

Fig.  53.  "  ': 


Cerebrospinal  meningitis.     Female  infant,  eight  months   of  age  ;   unconscious  on  admis- 
sion to  hospital;  fatal  issue.      (Meningococcus.) 


the  other  hand,  the  temj)erature  may  remain  persistently  high,  espe- 
cially in  the  rapidly  fatal  cases  of  the  malignant  type. 

In  the  chronic  cases  the  temperature  may  fall  to  and  continue 
within  normal  limits  for  days  or  even  weeks.  In  some  cases,  after 
the  temperature  has  remained  normal  for  days  or  weeks,  there  may 
be  a  so-called  recrudescence  of  temperature  of  an  intermittent  type 
extending  over  a  week  or  more.  This  does  not  preclude  ultimate 
recovery.  In  one  case  in  the  recent  epidemic  the  temperature  con- 
tinued of  the  intermittent  type,  with  the  remissions  mentioned  above, 
for  eight  weeks,  fell  to  the  normal  for  a  week,  rose  again,  continued 
intermittent  for  a  week,  and  finally  fell  to  the  normal  and  remained 
there.  In  this  respect  the  temperature  may  even  resemble  typhoidal 
curves  of  the  third  or  fourth  week. 


356 


TRE  SPECIFIC  INFECTIOUS  DISEASES. 


Spleen. — The  spleen  may  be  enlarged  in  some  cases. 

Ear. — The  ear  may  be  the  seat  of  otitis  or  mastoiditis.  Deafness, 
especially  where  the  base  is  involved,  may  supervene  very  early. 

Anterior'  Fontanelle. — The  anterior  fontanelle  in  infants  and 
children  in  whom  the  structure  has  not  closed,  may  be  tense  or  dis- 
tinctly bulging;  and  in  those  cases  in  which  there  is  considerable 
accumulation  of  fluid  the  posterior  fontanelle  may  reopen. 

Shin. — In  many  of  my  cases  there  has  not  been  that  prevalence 
of  skin  rash  described  by  most  authors.  It  has  been  only  in  the 
last  epidemic  of  1904  in  which  skin  eruptions  were  prevalent.  They 
included  the  roseola  resembling  that  of  typhoid  fever.  The  roseola 
appears,  as  a  rule,  at  the  outset  of  the  disease,  and  may  recur  in  the 


Fig.  54. 

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Cerebrospinal   meningitis.     Female   child,   eight  years  of  age ;   temperature  at  two 
extremes  of  the  illness.     Recovery.      (Meningococcus.) 

course  of  the  disease.  Purpuric  spots  extending  over  the  general  sur- 
face are  common  at  the  outset,  as  well  as  ecchymoses,  and  these  may 
disappear  within  a  few  days,  leaving  absolutely  no  trace  of  their 
presence;  or  recurrent  crops  of  ecchymoses  and  petechise  may  appear 
in  the  course  of  the  disease.  Herpes  labialis  varies  in  different 
epidemics  as  to  its  frequency,  being  absent  in  the  majority  of  cases 
in  some  epidemics,  and  being  frequent  in  others.  Herpetic  eruptions 
may  occur  elsewhere  on  the  trunk  or  extremities.  I  have  seen  exten- 
sive herpes  on  the  hand.  One  case  has  come  to  my  notice  in  which 
the  herpes  were  quite  generally  distributed  over  the  trunk  and 
extremities. 

Complications. — In  some  epidemics  of  cerebrospinal  meningitis 
there  are  few  complications.  Those  cases  which  recover  do  so  with 
very  little  to  show  that  the  nervous  system  in  any  of  its  extent  has 
been  severely  compromised.  The  eyesight  is  not  injured,  nor  is  there 
subsequent  hydrocephalus  in  any  cases.     In  other  words,  the  recov- 


MENINGITIS.  357 

eries  when  they  occur  are  complete  and  satisfactory.  This  is  espe- 
cially true  of  small  epidemic  outbreaks  occurring  over  the  course  of 
years.  In  the  recent  epidemic  of  1904,  however,  the  complications 
were  more  frequent;  joint  complications  were  observed  in  2  cases  of 
a  series  of  30 ;  blindness  was  not  an  uncommon  complication,  as  also 
deafness.  Recovery  was  incomplete,  with  hydrocephalus  in  several 
cases  of  a  series  of  30.  Pneumonia  was  observed  as  a  complication 
of  cerebrospinal  meningitis  of  the  epidemic  type  in  2  fatal  cases. 

Sequelae. — Recovery  may  take  place  without  compromise  of  any 
of  the  senses  or  functions  of  the  patient.  Both  in  young  and  older 
children  hydrocephalus,  either  of  a  mild  or  severe  type,  may  super- 
vene in  the  course  of  the  disease ;  it  may  run  a  short  course  and  the 
patient  recover  with  a  mild  form  of  hydrocephalus,  which  in  years 
gives  rise  to  nervous  symptoms,  such  as  partial  paresis  or  epileptic 
form  of  convulsions.  Severe  types  of  hydrocephalus  lead  in  many 
cases  to  permanent  idiocy  or  imbecility,  with  or  without  paralysis. 
In  some  cases  blindness  or  deafness  results  as  a  direct  cause  of  menin- 
gitis. Arthritis,  which  sometimes  complicates  the  disease,  has  a  ten- 
dency to  get  well  and  leave  no  marks  of  its  presence.  Many  patients 
recover  with  so-called  sensitive  spines,  or  paresis  of  certain  sets  of 
muscles,  which  later  in  life  becomes  apparent. 

Optic  neuritis  or  blindness  occurring  in  the  course  of  the  disease 
very  frequently  retrogrades,  and  the  patients,  on  recovery,  bear  nO' 
marks  of  any  ocular  lesion. 

Characteristics  of  the  Fluid  Obtained  by  Lumbar  Puncture.^ — The 
fluid  obtained  by  lumbar  puncture  in  cases  of  meningitis,  studied 
both  as  to  cytology  and  bacteriology,  is  of  particular  interest  as 
regards  the  possibility  of  making  a  diagnosis.  The  cytology  of  the 
fluid  obtained  in  cerebrospinal  meningitis  shows  a  preponderance  of 
the  polynuclear  leucocytes.  In  a  small  percentage  of  cases  the  mono- 
nuclear cells,  contrary  to  the  general  belief,  may  be  prevailing  ele- 
ments, thus  closely  resembling  what  is  seen  in  tuberculous  meningitis. 
In  chronic  cases  mononuclear  leucocytes  abound ;  and  in  these  cases, 
especially  those  of  the  basic  type  described  by  Still,  the  cytological 
picture  resembles  that  of  tuberculous  meningitis.  The  fluid  obtained 
by  lumbar  puncture  in  cerebrospinal  meningitis  may  be  quite  clear, 
with  scarcely  any  sediment,  and  may  be  markedly  purulent,  in  this 
respect  differing  from  the  fluid  obtained  in  tuberculous  forms  of 
meningitis,  which  is  clear  in  at  least  TO  per  cent,  of  the  cases. 

Bacteria. — In  the  vast  majority  of  cases  of  cerebrospinal  menin- 
gitis the  Diplococcus  meningitidis  intracellularis  of  Weichselbaum 
was  found  at  one  time  or  another,  either  in  leucocytes  or  outside  of 
the  leucocytes.  In  the  chronic  cases,  however,  there  are  times  in 
which  the  Diplococcus  intracellularis  is  not  found.     This  is  especially 


358  '  THE  SPECIFIC  INFECTIOUS  DISEASES. 

true  of  the  posterior  basic  cases.  In  those  cases  in  which  the  diplo- 
coccus  has  not  been  found  during  life  in  the  fluid  obtained  by  lumbar 
puncture,  it  may  be  discovered  postmortem  in  the  fluid  obtained  from 
the  ventricles  of  the  brain.  I  have  recently  punctured  the  brain  ven- 
tricles of  infants  during  life  in  cerebrospinal  meningitis.  The  char- 
acteristics of  the  fluid  are  identical  with  those  of  the  fluid  obtained 
by  lumbar  puncture  in  the  same  cases. 

Course  of  the  Disease. — The  course  of  the  disease  after  the  symp- 
toms are  fully  developed  in  typical  cases  has  been  indicated  in  the 
first  part  of  this  article.  The  patient  lies  unconscious,  the  head  is 
retracted,  and  in  some  cases  the  back  arched.  The  delirium  is  con- 
stant, and  the  patients  complain  of  headache.  The  neck  is  rigid; 
some  patients  complain  also  of  j)ain  in  the  course  of  the  sciatic  nerves. 
•When  disturbed  they  cry  out  with  pain.  There  may  be  rigors, 
during  which  the  patients  become  cyanosed  and  the  heart  feeble. 
The  respirations  are  shallow  and  irregular.  If  the  case  lasts  over 
a,  week  the  patients  may  refuse  nourishment,  and  on  this  account 
marked  emaciation  sets  in. 

In  some  cases  the  disease  takes  on  an  abortive  type.  After  a 
period  of  headache,  fever,  vomiting,  intervals  of  remission  of  all 
symptoms,  including' temperature,  alternate  with  intervals  in  which 
the  temperature  runs  an  intermittent  course,  with  a  return  of  the 
headache,  stupor,  and  uneasiness,  convalescence  finally  sets  in,  and 
the  patients  rapidly  recover. 

Other  cases  result  fatally  in  a  few  days.  Some  cases  run  a  course 
of  from  eight  to  fifteen  weeks,  with  the  temperatures  described,  great 
emaciation,  and  finally  make  an  incomplete  recovery.  Others  attain 
a  freedom  from  symptoms,  but  emaciation  and  paralysis  persist,  or 
even  blindness  and  deafness,  until  an  intercurrent  affection  ends  the 
sufferings  of  the  patient.  As  will  be  shown,  there  are  few  recoveries 
in  children  below  two  years  of  age.  In  other  cases  recovery  takes 
place,  but  idiocy,  hydrocephalus,  blindness,  or  palsy  may  persist. 

Diagnosis. — Cerebrospinal  meningitis  must  be  difl'erentiated  from 
tubfrculous  meuiugitis,  typhoid  fever,  and  pneumonia  with  cerebral 
sym])toms. 

It  is  distinguished  from  tuberculous  meningitis  by  the  sudden 
onset,  its  continued  or  intermittent  higher  febrile  movement,  the 
early  onset  and  marked  rigidity  of  the  neck  and  opisthotonos,  and, 
as  has  been  intimated,  the  higher  leiicocytosis,  and  finally  by  the 
examination  of  the  fluid  obtained  by  lumbar  puncture.  Cerebro- 
spinal meningitis  is  distinguished  from  ty])hoi(l  fever  by  the  fact  that 
in  the  latter  disease  there  is  a  leucopenia  and  a  constant  enlargement 
of  the  spleen  with  Widal  reaction.  On  the  other  hand,  there  may 
be  cases  of  ty])li()i(l  fever  in  wbicli  llic  cercljral  symptoms  are  very 


MENINGITIS.  359 

marked  and  in  wbicli  a  meningitis  may  be  present,  due  to  an  inva- 
sion of  the  meninges  of  the  brain  and  cord  by  the  typhoid  bacillus. 
In  this  set  of  cases  the  diagnosis  will  be  very  difficult  without  the  aid 
of  a  lumbar  puncture.  This  latter  procedure  should  be  made  in  order 
to  exclude  the  severer  affection  of  cerebrospinal  meningitis.  A  pneu- 
monia with  cerebral  symptoms  will  at  the  outset  closely  resemble  a 
cerebrospinal  meningitis,  especially  in  very  young  children.  Even 
if  an  examination  of  the  lungs  reveals  a  pneumonia  during  an  epi- 
demic of  meningitis,  we  cannot  always  exclude  the  latter  disease 
without  resort  to  a  lumbar  puncture,  for  cases  of  meningitis  of  the 
epidemic  cerebrospinal  type  caused  by  the  intracellular  diplococcus 
are  met  in  which  pneumonia  is  present  as  a  complication.  On  the 
other  hand,  pneumonia  per  se  with  cerebral  symptoms  does  not,  as  a 
rule,  give  us  the  very  niarked  rigidity,  opisthotonos,  petechise,  intense 
cephalalgia,  and  Kernig  symptom  seen  in  cerebrospinal  meningitis. 
I  have,  however,  met  isolated  cases,  both  of  pneumonia  and  typhoid 
fever  with  cerebral  symptoms,  in  which  a  Kernig  symptom  was 
obtained,  as  well  as  the  so-called  tache  cerebrale  of  Trousseau, 
although  these  cases  are  certainly  exceptional;  in  any  doubtful  case 
we  should  not  hesitate,  as  has  been  said,  to  resort  to  lumbar  puncture 
in  order  to  clear  up  a  given  case. 

Prognosis. — The  mortality  of  cerebrospinal  meningitis  varies 
largely  with  the  severity  of  the  infection  and  in  different  epidemics. 
In  some  epidemics  the  malignant  cases  seem  to  predominate;  that 
is,  those  cases  which  die  within  a  short  time  (from  twenty-four  hours 
to  five  days)  after  the  onset  of  the  disease.  On  the  other  hand,  in 
small  epilemics  the  mortality  may  not  exceed  48  per  cent.  There 
are  epidemics  in  which  the  mortality  has  risen  as  high  as  90  per  cent. 
Especially  fatal  are  the  postero-basic  cases  and  those  attended  by 
malignant  features  at  the  very  outset  of  the  disease.  The  prognosis, 
unfortunately,  cannot  be  predicted  in  cerebrospinal  meningitis,  either 
from  the  nature  of  the  fluid  obtained  by  lumbar  puncture,  or  from 
the  condition  of  the  blood  as  reflected  in  the  leucocyte  count,  or  the 
range  of  the  temperature.  We  can  only  say  that  it  is  especially  fatal 
the  younger  the  patients.  We  have  records,  however,  of  cases  of 
cerebrospinal  meningitis  occurring  in  infants  of  five  months  and  one 
year  of  age,  substantiated  by  culture  and  lumbar  puncture,  in  which 
recovery  occurred. 

The  prognosis  has  recently  been  much  improved  by  the  serum 
treatment  of  Flexner.  In  400  cases  collected  by  Flexner  and  Jobling 
treated  by  their  serum,  the  mortality  was  lowest  in  cases  treated  in 
the  first  three  days  of  the  disease  (11  to  13  per  cent.),  in  cases  from 
the  second  to  the  twentieth  year;  on  the  seventh  day  of  the  disease 
the  mortality  of  injected  cases  ranged  from  24  to  26  per  cent.     Below 


360  THE  SPECIFIC  INFECTIOUS  DISEASES. 

2  years  of  age  the  mortality,  when  treated  from  the  fourth  to  the 
seventh  day,  was  16  to  25  per  cent.,  and  50  to  66  per  cent,  when 
treated  later. 

Treatment. — Serum. — One  of  the  greatest  advances  of  modern 
medicine  is,  as  with  diphtheria,  the  serum  treatment  of  cerebrospinal 
meningitis  of  the  meningococcus  type.  Among  the  various  sera  which 
have  been  perfected  and  proj^osed,  the  Flexner  serum  is  now  by  selec- 
tion the  one  utilized.  Its  action  is  bacteriolytic  and  therefore  the 
great  advantage  in  its  use  is  the  proposal  by  Flexner  to  inject  this 
serum  into  the  spinal  canal  and  thus  reach  the  bacteria  directly. 

It  has  been  found  that  after  one  or  more  injections  the  number 
of  bacteria  (meningococci)  is  gi'eatly  reduced  and  the  fluid  withdrawn 
from  the  cerebrospinal  canal  contains  either  very  few  bacteria  or  none 
at  all.  It  thus  acts  in  a  manner  differently  from  the  diphtheria 
serum  which  is  injected  subcutaneously  and  affects  the  disease  through 
a  contained  antitoxin.  It  is  well  to  remember  that  the  Flexner  serum 
is  of  virtue  only  in  cases  of  the  meningococcus  variety. 

The  serum  should  be  used  as  soon  as  the  symptoms  of  meningitis 
are  apparent.  A  tentative  lumbar  puncture  should  be  made  as  early 
as  possible.  Before  lumbar  puncture  it  is  not  always  possible  to 
diagnose  the  exact  form  of  meningitis  present.  Therefore  to  avoid 
delay  which  may  be  harmful  a  so-called  exploratory  puncture  is  made 
at  the  start.  If  the  fluid  thus  obtained  is  turbid  an  immediate  injec- 
tion of  serum  is  made  and  the  cerebrospinal  fluid  examined.  If  men- 
ingococci are  found  the  injection  of  serum  is  repeated  until  the 
symptoms  indicate  that  the  disease  is  under  control  and  convalescence 
established. 

Before  proceeding  to  puncture,  every  piece  of  apparatus  necessary 
should  be  in  readiness.  The  needle  is  carefully  boiled,  the  tubing 
to  be  attached  to  the  needle  is  sterilized,  as  also  the  funnel  by  which 
the  serum  is  introduced  into  the  canal.  The  serum  having  been  care- 
fully warmed  to  the  temperature  of  the  body,  the  site  of  puncture  is 
cleansed,  the  needle  introduced,  and  the  fluid  of  the  subarachnoid 
space  allowed  to  flow  out.  After  withdrawal  of  30  to  40  or  more  c.c. 
of  fluid,  30  c.c.  of  the  serum  is  allowed  to  flow  slowly  into  the  canal 
just  evacuated.  The  syringe  has  long  been  discarded  by  me  for  the 
Quincke  funnel.  After  all  the  serum  has  flowed  into  the  canal  the 
needle  is  withdrawn  and  the  puncture  sealed  with  a  sterile  gauze 
dressing.  Flexner  and  Dunn  advise  the  repetition  for  three  succes- 
sive days  of  30  c.c.  of  serum.  In  young  infants  this  should  be  done 
on  account  of  the  dangerous  nature  of  the  disease. 

In  older  children  it  is  well  to  study  the  symptoms  closely  and  to 
repeat  the  injections  on  successive  days  as  needed.  In  some  cases  I 
have  found  that  two  injections  sufficed  to  bring  about  convalescence. 


MENINGITIS.  361 

I  have  carried  out  the  intracranial  injection  of  serum  in  infants 
in  whom  the  effect  of  the  lumbar  punctures  was  not  apparent  after 
the  first  few  injections  of  serum  and  in  whom  basic  symptoms  were 
in  evidence.  Gushing  and  Knox  first  carried  out  these  intracranial 
injections  of  serum  in  posterior  basic  cases.  My  experience  with  this 
method  as  yet  is  too  limited  to  make  any  positive  statements. 

In  these  cases  the  puncture-needle  is  entered  with  the  infant  in 
the  recumbent  posture,  in  the  parieto-f rental  angle  of  the  anterior 
fontanelle  to  one  side  of  the  median  line.  The  inferior  angle  is 
chosen.  The  fluid  comes  through  the  canula  quite  readily  and  the 
serum  is  introduced  in  the  same  manner  as  in  lumbar  puncture. 
Aseptic  precautions  as  to  shaving  of  the  head  aud  site  of  the  cranial 
puncture  are  very  important,  as  the  least  oversight  may  lead  to  a 
meningoencephalitis  due  to  a  mixed  infection. 

Lumbar  Puncture.- — The  symptoms  calling  for  lumbar  puncture 
are  increased  exudate  in  the  subarachnoid  space,  with  extreme  rigid- 
ity, opisthotonos,  coma,  delirium,  bulging  fontanelle ;  in  young  in- 
fants chills  with  subsequent  rises  of  temperature  are  indications  for 
a  repetition  of  and  introduction  of  serum  by  lumbar  puncture.  In 
those  cases  in  which  coma  and  delirium  supervene  at  the  very  outset 
of  the  disease,  lumbar  puncture  may  be  performed  within  twenty-four 
hours  of  the  onset  of  symptoms.  We  should  not  hesitate  after  the 
first  puncture  to  repeat  the  procedure  within  twenty-four  hours,  as 
indicated  above,  if  symptoms  either  recur  or  remain  stationary.  In 
young  infants  and  children  especially  repeated  lumbar  puncture 
seems  to  be  called  for  by  the  very  fact  that  in  these  subjects  the  con- 
tinued pressure  and  increase  of  fiuid  in  the  subarachnoid  space  and 
in  the  ventricles  of  the  brain  increases  the  tendency  to  dilatation  of 
the  ventricles,  a  serious  complication  which  may  lead  to  collapse 
symptoms,  sudden  death,  or  ultimate  chronic  hydrocephalus.  In 
those  cases  in  which  at  the  outset  of  the  disease  the  head  retraction  is 
very  marked,  the  lumbar  puncture  is  sometimes  unsatisfactory,  inas- 
much as  little  fluid  is  withdrawn.  In  these  cases  the  exudate  at  the 
base  of  the  brain  and  the  extreme  retraction  of  the  head  may  cut  off 
the  communication  of  the  subarachnoid  space  and  spinal  cord  with 
the  ventricles  of  the  brain.  The  canal  of  Majendie,  through  which 
this  communication  is  sustained,  is  in  these  cases  occluded.  These 
are  the  cases  in  which  ventricular  puncture  is  suggested. 

Lumbar  puncture  alone  is  not  curative.  It  relieves  symptoms  of 
headache  and  delirium.  It  removes  a  certain  amount  of  purulent 
exudate  which  is  a  menace  to  the  vital  structures  of  the  brain  and 
cord,  and  is  thus  a  method  of  drainage  rather  than  a  curative  meas- 
ure. It  may,  in  cases  of  sudden  distention  of  the  ventricles  of  the 
brain  with  fluid,  avert  death. 


362  TKE  SPECIFIC  IXFECTIOrS  DISEASES. 

The  amount  of  fluid  Tvitlidrawu  at  each  puncture  should  be  from 
30  to  50  C.C.,  depending  greatly  on  the  extent  of  pressure  present,  as 
indicated  hv  the  manner  in  Tvhich  the  fluid  flows  from  the  puncture 
cannula.  If  the  fluid  flows  drop  by  drop,  a  small  amount,  20  to  30 
cc.  is  withdrawn.  In  some  cases  the  fluid  fairly  spurts  from  the 
cannula,  and  in  such  cases  50  c.c.  or  more  may  be  withdrawn.  In 
other  cases  the  exudate  is  so  thick  and  purulent  that  it  will  not  flow 
from  the  cannula  except  in  large,  thick  drops  at  long  intervals.  We 
should  not  in  these  cases  attach  a  syringe  to  the  cannula  and  apply 
suction  to  the  fluid,  for  in  this  way.  it  has  been  shown,  hemorrhages 
may  be  caused  in  the  spinal  cord  and  the  pia  of  the  brain.  Anses- 
thesia  is  not  needed  in  young  children  but  may  be  administered  to 
older,  boisterous  children.  As  might  be  supposed,  a  number  of  modi- 
fications on  the  procedure  of  simple  lumbar  puncture  have  been 
proposed. 

General  Treatment. — Aside  from  the  serum  treatment  of  cerebro- 
spinal meningitis  the  general  conduct  of  the  case  is  of  utmost  im- 
portance. 

Diet. — The  maintenance  of  the  nutrition  of  the  patient  is  a  most 
important  element  in  these  cases  of  meningitis.  In  those  cases  in 
which  the  patient  is  comatose  and  refuses  to  take  nourishment  by  the 
mouth,  it  is  a  difficult  problem  to  maintain  the  nutrition  of  the 
patient.  In  many  cases  nourishment  must  be  given  by  the  rectum, 
and  in  some  must  be  introduced  into  the  stomach  by  means  of  gavage. 
In  the  first  case  we  frequently  iind  that  after  nourishing  the  patient 
by  the  rectum  for  a  few  days  this  viscus  becomes  intolerant  and  very 
little  nourishment  is  retained.  Peptonized  milk  and  somatose  in  the 
form  of  enemata  are  the  most  available  forms  of  nourishment  by  the 
rectum.  Gavage  does  not  meet  our  ideals  as  to  nourishment  of  the 
patient,  because  there  is  resistance  to  this  procedure  on  the  part  of 
the  unfortunate  sufferers.  Thus,  each  individual  case  will  be  a 
problem  to  the  physician ;  some  patients  take  food  with  avidity,  and 
in  these  cases  milk  and  broths  are  the  principal  forms  of  nourish- 
ment given. 

Drugs  and  Hydrotherapy . — The  bowels  of  these  patients  are  gen- 
erally constipated,  and  from  time  to  time  a  cathartic  must  be  given; 
the  most  preferable  cathartics  are  the  mercurials,  calomel  in  dose  of 
^  to  2  grains,  are  given  to  clear  the  bowels.  This  may  be  repeated 
at  intervals  of  forty-eight  to  seventy-two  hours.  Enemata  do  not 
seem  to  reach  the  majority  of  cases.  The  headache  is  very  severe  in 
a  great  number  of  cases,  and  no  remedy  that  we  know  of  completely 
relieves  the  symptom.  Morphine  given  in  moderate  doses  relieves 
some  patients.  In  others  this  drug  is  not  well  borne,  and  the  patients 
seem  to  become  more  stupid  and  the  circulation  weaker  under  its 


MENINGITIS.  363 

continued  use.  The  author  has  tried  the  various  drugs  of  the  coal- 
tar  series. 

Pyramidon  in  doses  of  5  to  7  grains,  given  at  intervals  of  three 
to  four  hours,  seems  to  have  relieved  a  certain  percentage  of  cases. 
The  head  is  shaved  and  the  ice-cap  applied.  Even  this  procedure  is 
not  well  borne  by  some  patients,  and  they  strongly  protest  against  it. 
It  seems  to  increase  the  pain. 

The  delirium  is  treated  with  liberal  doses  of  mixed  bromides  of 
sodium,  potassium,  and  ammonia.  In  some  cases  chloral  in  moderate 
dose  is  added  to  this  mixture,  and  is  well  borne  by  the  patient.  It 
does  not  depress  the  circulation. 

The  irregularity  of  the  heart  which  is  present  in  a  large  number 
of  cases  does  not  call  for  any  active  treatment.  Alcoholic  stimulants 
should  be  avoided  if  possible,  as  there  seems  to  be  no  indication  for 
their  use.  One  of  the  principal  modes  of  meeting  restlessness,  the 
occasional  high  temperature,  the  rigors  and  accompanying  cardiac 
weakness,  is  the  systematic  use  of  warm  baths.  The  patients  are 
placed  in  a  warm  bath  of  a  temperature  of  105°  to  107°  F.  three 
times  in  the  twenty-four  hours.  Care  should  be  taken  to  lift  the 
patient  gently  from  the  bed  into  the  bath.  Massage  should  not  be 
performed  as  in  the  ordinary  bath  given  in  pneumonia,  while  the 
patient  is  in  the  bath,  inasmuch  as  this  friction  irritates  and  excites 
the  patient  and  seems  to  cause  a  great  deal  of  pain.  -  The  duration 
of  the  bath  should  be  from  five  to  ten  minutes.  The  time  for  giving 
it  should  be  chosen  when  the  temperature  is  on  the  rise,  the  irrita- 
bility of  the  patient  at  this  time  being  greatest.  If  the  heart  should 
become  very  weak,  camphor  is  indicated ;  if  possible,  by  the  stomach. 
If  this  is  not  feasible,  camphor,  in  the  form  of  camphorated  oil,  should 
be  given  subcutaneously. 

Acute  Lepto-meningitis  (Vertical  Meningitis). — In  this  form  of 
meningitis  the  vertex  or  superior  surface  of  the  brain  is  affected ;  the 
region  of  the  cerebrospinal  foramen  may  escape,  but  not  necessarily 
so,  and  in  some  cases  the  base  also  may  be  affected. 

Occurrence. — It  is  found  in  the  newborn  and  children  as  a  com- 
plication of  sepsis,  erysipelas,  pneumonia,  influenza,  diseases  of  the 
ethmoid  and  mastoid  bones,  perforation  of  the  bones  of  the  skull,  or 
suppurations  elsewhere,  such  as  retropharyngeal  abscess. 

Etiology. — The  essential  cause  is  an  invasion  of  the  tissues  of  the 
meninges  of  the  brain  by  streptococci,  pneumococci,  the  influenza 
and  coli  bacilli. 

These  cases  are  sometimes  diflicult  of  diagnosis,  because  in  many 
of  them  the  classical  symptoms  of  meningitis  are  absent.  In  the 
early  stages  of  the  disease  anatomically  there  is  dryness  and  opacity 
of  the  pia   hyperemia.      Later,    oedematous   conditions   of   the   pia 


364  TEE  SPECIFIC  INFECTIOUS  DISEASES. 

supervene  with  the  formation  of  lymph  and  fibrin  along  the  sulci 
and  in  the  tissue  of  the  pia  mater  and  on  its  surface.  Later,  the  puru- 
lent exudate  may  extend  over  the  surface  of  the  brain,  involving  not 
only  the  base  of  the  brain,  but  also  the  spinal  cord.  In  some  cases 
the  exudate  does  not  penetrate  the  ventricles  of  the  brain;  in  others 
inflammation  extends  into  the  ventricles.  In  this  form  of  meningitis 
there  are  complications  either  primary  or  secondary,  such  as  pneu- 
monia, empyema,  pericarditis. 

Symptoms. — The  diagnosis  is  difficult.  The  symptoms  are  often 
latent.  Retraction  of  the  head  is  very  often  absent,  and  ocular  symp- 
toms are  rarer ;  in  fact,  the  fundus  in  many  cases  is  found  to  be 
normal.  Vomiting  is  less  frequent  than  in  the  basic  forms  of  menin- 
gitis to  be  described,  or  in  the  cerebrospinal  forms  just  described. 
Convulsions  of  a  violent  character  may  be  present;  they  may  be 
repeated  throughout  the  disease,  and  are  associated  in  some  cases  with 
high  temperature ;  in  other  cases  they  are  absent.  These  convulsions 
may  be  epileptiform.  Clonic  spasms  may  be  local  at  first,  but,  as  a 
rule,  they  become  bilateral  and  general.  There  may  be,  as  in  menin- 
gitis, tonic  spasms.  The  duration  of  the  disease  is  shorter  than  in 
posterior  basic  meningitis,  may  last  from  one  to  two  days  to  as  many 
weeks,  and  in  exceptional  cases  may  become  chronic.  In  many  cases 
it  is  impossible,  unless  a  lumbar  puncture  is  made,  to  differentiate 
these  cases  from  tubercular  meningitis.  IsTor  is  it  possible,  if  the 
exudate  extends  to  the  spinal  cord  and  rigidity  sets  in,  to  differentiate 
a  so-called  vertical  case  from  an  ordinary  cerebrospinal  meningitis  of 
the  epidemic  type  unless  a  lumbar  puncture  is  made.  The  differen- 
tiation, therefore,  of  these  cases  must  depend  on  a  continued  observa- 
tion of  the  case  and  the  performance  of  lumbar  puncture. 

Posterior  Basic  Meningitis. — Posterior  basic  meningitis  is  so 
called  because  the  inflammation  affects  the  posterior  part  of  the  base 
of  the  brain  and  the  structures  in  this  location,  and  rarely  spreads  to 
the  vertex  of  the  brain,  at  most  only  affecting  the  tips  of  the  temporo- 
sphenoidal  lobes,  and  in  some  cases  extending  forward  to  the  optic 
commissure.  These  cases  were  flrst  described  by  Gee  and  Barlow, 
in  the  Bartholomeiv  Hospital  Reports  of  1878,  and  subsequently  by 
Still  in  1898. 

Occurrence. — The  affection  occurs  in  infants  and  children  below 
the  age  of  two  years,  and  is  rarely  seen  in  older  children.  I  have  seen 
exceptional  cases  in  children  of  three  and  five  years  of  age. 

Etiology. — These  cases,  according  to  Still,  and  confirmed  by  my 
own  observations,  are  caused  by  a  diplococcus  which  is  identical  with 
the  diplococcus  of  Weichselbaum,  Jager,  and  Leichtenstern,  an  intra- 
cellular diplococcus  not  staining  with  Gram's  method.  Although 
Still  thought  that  these  were  only  sporadic  cases  of  the  epidemic  form 


PLATE  XXI 


Posterior   Basic   Meningitis.      (Gee,  Barlow,  and  Still.) 
Author's  ease. 


MENINGITIS.  365 

of  cerebrospinal  meningitis,  it  can  now  be  said  that  they  are  seen  very 
frequently  and  in  large  numbers  in  epidemics  of  cerebrospinal  menin- 
gitis, and  may  occur  sporadically.  Thej^  are  only  specific,  inasmuch 
as  they  are  a  form  of  cerebrospinal  meningitis  as  it  occurs  in  younger 
children  and  infants. 

These  cases  divide  themselves  into  those  which  are  fatal  after  six 
weeks;  those  which  die  after  three  or  four  months  with  hydroceph- 
alus ;  and  those  which  recover.  In  the  first  set  of  cases  anatomically 
we  find  pus  and  lymph  at  the  base  of  the  brain  and  extending  down 
the  cord.  In  the  second  set  of  cases  there  is  simply  thickening  of  the 
pia  and  arachnoid,  with  adhesions  between  the  cerebellum  and  me- 
dulla. The  inflammation  may  spread  down  the  cord  to  a  varying 
degree  and  upward  along  the  lining  membrane  of  the  ventricles,  and 
afterward  along  the  base  as  far  as  the  optic  commissure.  In  the 
chronic  cases  there  may  be  adhesions  of  the  meninges  either  in  the 
anterior  part  of  the  base  of  the  brain  or  even  on  the  vertex,  showing 
that  this  has  been  slightly  involved.  The  adhesions  at  the  base  may 
unite  the  medulla  and  cerebellum  and  obliterate  the  foramen  of 
Magendie  or  the  fourth  ventricle.  This  results  in  accumulation  of 
fluid  in  the  ventricles  with  hydrocephalus.  In  some  cases  the  ven- 
tricular fluid  is  clear;  in  others  it  contains  flakes  of  fibrin  and  pus 
and  meningococci. 

As  has  been  shown,  complications  in  this  form  are  rare.  Occa- 
sional arthritis  is  found.  In  some  cases  Still  has  found  tuberculous 
foci  of  the  viscera,  which  he  considers  accidental.  In  other  cases 
the  middle  ear  may  contain  mucopurulent  secretion,  but  no  evidence 
of  the  extension  of  the  ear  disease  to  the  brain  or  meninges. 

Symptoms. — The  onset,  as  in  cerebrospinal  meningitis,  is  abrupt 
and  has  the  same  symptomatology.  The  most  characteristic  symp- 
tom clinically  of  these  cases  is  the  retraction  of  the  head.  This 
supervenes  early  and  continues  until  death  or  recovery  of  the  patient. 
Convulsions,  tonic  or  clonic,  occur  early  in  the  disease,  but  are  less 
frequent  than  in  meningitis,  involving  the  superior  surface  of  the 
brain  and  cord.  There  are  rigidity  of  the  limbs  and  opisthotonos, 
and  an  increase  and  diminution  of  this  rigidity,  in  the  course  of  the 
disease,  with  tetanic  contractures  of  the  upper  and  lower  extremities, 
as  shown  in  the  accompanying  drawings.  Vomiting  is  one  of  the 
first  or  early  symptoms,  and  may  occur  throughout  the  disease.  After 
the  disease  has  lasted  some  time  the  eyes  have  a  fixed  stare;  there 
may  be  strabismus  or  nystagmus ;  the  pupils  are  contracted,  or  later 
may  be  dilated.  Optic  neuritis  is  not  common,  though  the  patients 
may  be  blind.  If  the  anterior  fontanelle  is  still  open,  it  bulges  with 
the  increasing  hydrocephalus,  and  in  some  cases  the  posterior  fon- 
tanelle, which  may  have  been  closed,  is  reopened,  the  sutures  become 


366  TSE  SPECIFIC  INFECTIOUS  DISEASES. 

widely  separated,  and  the  children  finally  lay  unconscious  and  per- 
form automatic  movements  with  the  facial  muscles,  mouth,  and 
extremities. 

The  rigidity  and  retraction  in  some  cases  are  extreme;  the  opis- 
thotonos is  very  marked  at  times;  at  others  the  neck  rigidity  will 
relax,  hut  on  the  least  irritation,  either  of  friction  or  otherwise,  the 
opisthotonos  and  tetanic  spasms  recur  (Plate  XXII.).  Recovery 
may  take  place  with  retrograde  of  most  or  all  of  these  symptoms,  or 
imperfectly  so  with  hydrocephalus.  In  some  of  these  cases  the  tem- 
perature curve  at  first  is  high,  and  after  the  disease  has  lasted  some 
time  it  may  drop  to  the  normal  and  remain  there,  or  rise  a  degree 
above  the  normal,  at  times  thus  simulating  tuberculous  meningitis; 
or  the  temperature  may  be  normal  for  periods  of  weeks  and  then  sudt 
denly,  without  any  apparent  cause,  show  wide  variations,  with  high 
temperatures  during  certain  parts  of  the  day  and  subnormal  tempera- 
ture at  others.     Death  may  supervene  suddenly  without  '^ause. 

Prognosis. — The  prognosis  is  very  bad.  There  are  few  recoverieiS, 
and  in  an  ej^idemic  most  of  these  children  die  or  develop  an  incurable 
hydrocephalus. 

Treatment. — The  treatment  at  first  is  the  same  as  that  outlined  in 
cerebrospinal  meningitis;  that  is,  an  early  use  of  the  serum.  In 
the  chronic  state  the  treatment  is  directed  toward  the  relief  of  the 
hydrocephalus.  As  soon  as  this  is  established  or  evident,  repeated 
lumbar  puncture  should  be  performed,  in  order  to  stay  the  increase 
of  the  fluid  in  the  ventricles,  and,  if  possible,  effect  a  cure  of  the: 
hydrocephalus ;  this  is  not  always  possible.  In  these  cases  the  Flex-: 
ner  serum  is  introduced  into  the  ventricles  of  the  brain,  which  are 
punctured  through  the  anterior  fontanelle.  The  contained  exudate 
is  withdrawn  and  the  serum  introduced.  The  operation  is  repeated 
on  both  ventricles  in  succession.  So  far  the  results  have  not  been 
encouraging  or  conclusive.  The  treatment  of  the  symptoms  are  the 
same  as  that  laid  down  for  cerebrospinal  meningitis. 

Meningitis  Serosa  (Quincke)  (Acute  Internal  Hydrocephalus}. 
— Meningitis  serosa,  or  acute  internal  hydrocephalus,  must  not  be 
confounded  with  tuberculous  meningitis,  which  formerly  was  called 
acu.te  internal  hydrocephalus.  Meningitis  serosa  was  described  in 
1893  by  Quincke.  Four  years  later  Bonninghaus  reported  some 
of  these  cases,  and  since  then  a  number  have  been  described  in  the 
literature. 

Occurrence  and  Definition.' — It  is  a  comparatively  rare  disease,  and 
occurs  only  between  the  ages  of  one  and  five  years.  In  consists 
of  a  serous  inflammation  of  the  extra-  and  intra-cerebral  pia  mater, 
and  as  a  consequence  of  this  inflammation  there  is  an  inflammatory 
oedema  in  the  subarachnoidal  space,  accompanied  by  acute  internal 


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MENINGITIS.  367 

hydrocephalus,  or  serous  exudate  in  the  ventricles  of  the  brain.  We 
have  two  forms  of  this  condition:  in  one  the  brain  and  membranes 
are  found  to  be  the  seat  of  inflammatory  oedema,  in  which  the  exu- 
date in  the  ventricles  is  comparatively  small  in  amount ;  in  the  other, 
the  more  common  form,  there  is  a  very  large  exudate  in  the  ven- 
tricles, and  the  membranes  of  the  brain  and  pia  mater  are  but  little 
affected. 

Etiology. — The  etiology  is  not  quite  clear.  Quincke  insists  that 
the  condition  may  occur  idiopathically,  in  a  manner  similar  to  an 
idiopathic  pleurisy.  Later  authors  are  inclined  to  regard  serous 
meningitis,  however,  as  an  infectious  process,  due  to  the  invasions  of 
staphylococci  or  streptococci,  which  are  found  in  the  ventricular  fluid 
removed  through  lumbar  puncture  or  postmortem.  Some  of  these 
cases  may  follow  a  chronic  hydrocephalus ;  others  may  be  traumatic 
or  complicate  an  acute  febrile  disease,  such  as  typhoid  fever  or 
pneumonia. 

Symptoms. — The  symptoms  are  not  always  marked,  and  it  is  not 
always  possible  to  recognize  the  disease  with  certainty.  The  differ- 
ential diagnosis  from  other  forms  of  meningitis,  such  as  the  tuber- 
culous form,  is  made  with  the  greatest  difficulty.  The  disease  may 
begin  with  varying  symptoms.  The  children  are  peevish  and  restless ; 
they  refuse  to  take  nourishment.  There  may  be  constipation,  dis- 
turbances of  the  process  of  digestion,  and  flnally  vomiting,  with  con- 
tinued emaciation.  The  temperature  in  all  cases  thus  far  observed 
is  raised  but  little  above  the  normal;  or,  if  raised  to  103°  F.,  rapidly 
falls  again  to  the  normal.  The  pulse  may  be  normal  or  slightly  in- 
creased in  rapidity.  A  constant  symptom  in  children  below  fourteen 
months  is  that  the  head  increases  in  circumference,  the  sutures  are 
forced  apart,  and  the  anterior  fontanelle  becomes  tense  and  bulging. 
The  cerebral  syiuptoms  consist  mostly  of  sopor,  uneasiness,  strabis- 
mus, and  nystagmus.  Sooner  or  later  convulsions  appear,  involving 
most  of  the  musculature  or  gToups  of  muscles.  In  some  cases  an 
early  optic  neuritis  has  been  observed. 

The  course  of  the  disease  is  a  protracted  one,  inasmuch  as  the 
symptoms  may  extend  over  weeks  or  months,  ending  finally  in  death, 
preceded  by  an  increasing  cachexia. 

In  those  cases  which  have  recovered,  the  circumference  of  the 
head  has  returned  to  its  normal  dimensions. 

Morbid  Anatomy.- — The  most  striking  lesions  found  post-mortem 
are  a  dilatation  of  the  ventricles  of  the  brain  with  an  increased  amount 
of  intraventricular  fluid,  by  which  the  surface  of  the  brain  is  com- 
pressed and  the  convolutions  flattened.  The  ependyma  is  swollen, 
thickened,  and  the  surface  granular.  The  choroid  plexus  is  hyper- 
semic.     The  membranes  of  the  brain  may  be  dull  and  more  or  less 


368  THE    SPECIFIC    INFECTIOUS    DISEASES. 

hypersemic.  In  some  rare  cases,  at  the  base  of  the  brain  a  circum- 
scribed purulent  meningitis  has  been  described,  which  supports  the 
view  that  serous  meningitis  may  follow  a  localized  condition  of  this 
character. 

A  characteristic  of  serous  meningitis  is  the  cloudy  swelling  with 
proliferation  and  desquamation  of  the  cells  of  the  ependyma,  and 
cellular  infiltration  of  the  brain  substance  beneath  the  ependyma  with 
round  cells,  especially  along  the  bloodvessels.  In  such  cases  there  is 
really  an  ependymitis  or  meningitis  ventricularis. 

Diagnosis. — The  diagnosis  of  serous  meningitis  must  be  made 
from  meningitis  of  other  varieties,  especially  of  the  tuberculous  or 
cerebrospinal  type.  The  author  is  inclined  to  believe  that  during  life 
a  very  careful  exclusion  of  every  possible  infection  is  the  first  step 
toward  the  diagnosis.  It  is  a  well-known  fact  that  forms  of  otitis 
media  purulenta  will  cause  cerebral  symptoms  and  even  an  increase 
in  the  intraventricular  fluid,  and  such  otitis  is  apt  to  be  overlooked, 
unless  thought  of  at  the  time  a  diagnosis  is  made.  The  patient,  there- 
fore, would  run  greater  danger  from  such  an  accident,  and  would  lose 
a  chance  of  recovery  if  the  diagnosis  of  otitis  or  mastoid  disease  were 
too  long  delayed. 

Optic  neuritis,  which  I  have  seen  in  two  cases,  may  be  present 
in  forms  of  meningitis  of  the  cerebrospinal  type,  although  Beck  puts 
much  stress  on  this  phenomenon.  Lumbar  puncture  will  aid  more 
in  the  diagnosis  than  any  other  procedure.  The  puncture  fluid  in 
cases  of  meningitis  serosa  thus  far  published  contained  no  micro- 
organisms, is  of  low  speciflc  gravity,  generally  1.007,  contains  1  to 
1.5  per  cent,  of  albumin,  and  very  few  if  any  cellular  elements  beyond 
those  of  a  few  blood-corpuscles.  On  the  other  hand,  a  tuberculous 
meningitis  would  give  a  puncture  fluid  which,  though  it  might  in  a 
certain  percentage  of  cases  be  devoid  of  micro-organisms,  would  con- 
tain a  number  of  mononuclear  lymphocytes.  In  cerebrospinal  men- 
ingitis the  puncture  fluid  would  contain  micro-organisms  unless  the 
meningitis  was  of  a  chronic  variety,  in  which  form  the  micro-organisms 
might  be  absent.  In  cerebrospinal  meningitis,  however,  a  study  of 
the  puncture  fluid  would  again  aid  us,  inasmuch  as  it  would  show  a 
preponderance  of  the  polynuclear  leucocytes. 

MUMPS. 

(Epidemic  Parotitis.) 

Mumps  is  an  infectious  and  contagious  disease  of  the  parotid 
gland,  at  times  involving  the  other  salivary  glands  as  well  as  the 
testis  or  ovary. 

Etiology. — Parotitis  is  endemic  in  large  cities,   and  frequently 


MUMPS. 


369 


becomes  epidemic  in  schools  and  institutions  where  large  numbers  of 
children  are  congregated.  It  is  most  common  among  children  of 
school  age,  because  they  are  more  exposed  to  infection  than  children 
at  an  earlier  or  later  period  of  life.  Girls  and  boys  are  attacked  with 
the  same  frequency.  It  may  occur  in  the  newly  born  infant.  The 
author  has  seen  a  case  in  an  infant  three  weeks  of  age. 

The  essential  cause  of  mumps  is  unknown.  Laveran  and  Catlin 
describe  micrococci  which  they  found  in  the  blood  and  in  the  glandu- 
lar lymph  of  the  parotid  and  testis.     These  micrococci  were  arranged 

Fig.  55. 


^' 


Bilateral  parotitis. 


in  twos  and  fours,  did  not  stain  by  the  Gram  method,  and  were  1  to 
1.5  micromillimetres  in  diameter.  Michaelis  and  Bein  isolated  an 
intracellular  chain-forming  diplococcus  from  Steno's  duct.  The  theory 
thus  far  advanced  is  that  these  micro-organisms  gain  access  to  the 
parotid  through  the  duct.  The  period  of  incubation,  according  to 
Rilliet  and  Lombard,  may  vary  from  seven  to  twenty-six  days. 

Morbid  Anatomy. — As  the  disease  is  rarely  if  ever  fatal,  oppor- 
tunities to  determine  the  morbid  conditions  have  been  few.  Virchow 
first  described  the  condition  of  the  gland  as  one  of  inflammatory 
serous  and  cellular  infiltration  of  the  intra-acinous  and  peri-acinous 

24 


370 


THE   SPECIFIC   INFECTIOUS   DISEASES. 


connective  tissue.      The   outcome   is   resolution;    induration   rarely 
remains. 

Symptoms. — There  is  a  prodromal  period,  during  which  the  pa- 
tient is  attacked  with  chilly  sensations  or  a  chill,  and  sometimes  with 
vomiting.  There  is  pain  in  the  region  of  the  ear,  and  also  a  ringing 
in  the  ears  and  deafness.  There  is  also  a'febrile  movement,  the  tem- 
perature in  some  cases  mounting  to  104°  F.  (40"^  C).  The  tem- 
perature may  be  normal  throughout  the  disease.  There  may  be 
headache  and  loss  of  appetite.  After  these  symptoms  have  lasted 
awhile,  the  face  becomes  swollen,  as  a  rule  on  one  side  only  (Fig.  55). 

Fig.  56. 


Parotitis  involving  tlie  submaxillary  glands,  lateral  view.     Boy,  four  years  of  age. 

This  swelling  gives  the  face  an  uneven  contour,  and  is  the  charac- 
teristic symptom.  In  older  children  it  causes  a  feeling  of  tenseness 
and  pain  on  mastication.  Sometimes  patients  are  averse  to  opening 
the  mouth  on  account  of  the  pain.  In  young  infants  there  is  drool- 
ing. In  the  majority  of  cases,  after  the  swelling  has  lasted  three  or 
four  days  and  is  subsiding,  the  opposite  side  becomes  affected.  In 
addition  to  the  swelling  of  the  parotid  there  is  also  intumescence 
of  the  lymph-nodes  of  the  neck  at  the  angle  of  the  jaw  and  of  the 
node  on  the  parotid  gland  in  front  of  the  ear.  Frequent]}^  the  sub- 
maxillary glands  are  also  swollen,  giving  the  whole  face  a  rounded 
contour.     In  most  cases  the  general  condition  of  the  patients  is  good 


MUMPS. 


371 


and  there  is  very  little  discomfort.  Other  cases  have  considerable 
pain  and  constitutional  disturbance.  In  all  my  cases  there  was  dis- 
tinct angina  and  svv^elling  of  the  tonsils.  In  a  newly  born  baby  there 
was  swelling  of  the  tissues  underneath  the  jaw  and  about  the  larynx, 
with  croupy  breathing  indicating  cedema  of  the  mucous  membrane 
of  the  larynx. 

English  writers  have  described  cases  in  which  the  submaxillary 
glands  alone  were  involved,  the  inflammation  being  strictly  limited 
to  the  glands  on  both  sides  (Fig.  56).     I  have  seen  cases  of  this  kind. 

Complications. — The  testes  and  epididymis  in  boys  and  the  ovaries 
and  glands  of  Bartholini  in  girls  may  become  affected.     There  may 

Fig.  57. 


Angiuiiia   uT  the  parotid  simulatiug  mumps. 


be  ardor  urinpe  and  a  urethral  discharge.  These  complications  are 
not  so  common  as  the  text-books  declare.  Hydrocele  may  occur  with 
the  orchitis.  I  have  seen  a  case  of  this  kind  in  a  very  young  infant. 
The  urine  may  show  a  trace  of  albumin,  or  in  very  rare  cases  there 
may  be  blood  in  the  urine.  Endocarditis,  pericarditis,  rheumatism, 
and  osteomyelitis  have  been  reported  as  complications,  but  the  author 
has  never  met  such  cases.  Parotitis  complicating  pneumonia  has 
been  observed  in  a  boy  of  six  years,  and  in  another  case  otitis  and 
parotitis  were  present  at  the  same  time.     In  rare  cases  the  breasts 


372  THE    SPECIFIC   INFECTIOUS    DISEASES. 

and  lachrymal  glands  are  affected.  Parotitis  may  be  a  complication 
of  typhoid  fever,  measles,  varicella,  and  influenza. 

Course. — The  disease  is  at  its  height  in  from  three  to  six  days,  and 
runs  its  course  in  from  seven  to  fourteen  days.  Mild  cases  may  last 
only  two  days.  Severe  cases  are  rare.  These  present  cerebral  symp- 
toms and  sveelling  of  the  tissues  about  the  neck  simulating  angina 
Ludovici,  with  considerable  dyspnoea.  Cases  of  recurrent  mumps, 
continuing  for  from  four  to  six  weeks,  are  recorded.  When  suppura- 
tion occurs,  it  is  probably  the  result  of  some  mixed  infection. 

Diagnosis. — The  diagnosis  is  not  difficult.  Uncertainty  as  to 
whether  the  parotid  is  affected  or  not  will  be  dispelled  by  drawing  a 
line  parallel  with  the  lower  border  of  the  jaw;  the  parotid  swelling 
will  be  above  the  line  and  the  lymph-nodes  of  the  neck  below  it  (Fig. 
57).  In  swelling  of  the  mastoid  region  the  ear  is  raised  from  the 
skull,  while  in  parotid  swelling,  even  if  it  occur  behind  the  ear,  that 
organ  remains  in  its  normal  position.  The  swelling  of  parotitis 
never  fluctuates,  but  is  elastic  in  character. 

Prognosis.— The  prognosis  of  mumps  is  good;  the  majority  of 
cases  recover  without  complications.  If  the  kidneys,  endocardium 
and  pericardium  are  affected,  the  prognosis  will  be  influenced  by  the 
course  of  these  affections.  I  have  never  known  parotitis  to  result 
fatally. 

Treatment. — The  patients  are  isolated  and  kept  in  bed  as  long  as 
symptoms  are  present.  The  parotid  is  anointed  twice  daily  with 
warm  oil  of  hyoscyamus  and  covered  with  cotton.  The  bowels  should 
be  regulated  with  a  saline  cathartic.  The  diet  should  be  assimilable. 
The  affection  cannot  be  controlled  by  means  of  drugs.  Pain  and 
fever  are  treated  on  general  principles. 

PERTUSSIS    CONVULSIVA. 

(  Wlwoping-cougli.) 

Pertussis  is  an  acute  specific  infectious  disease,  caused  by  a  micro- 
organism, probably  of  the  influenza  group.  It  is  characterized  in 
the  majority  of  cases  by  a  spasmodic  cough  accompanied  by  a  so- 
called  whoop. 

Pertussis  is  not  only  infectious,  but  it  is  also  contagious.  It  is 
propagated  through  the  atmosphere  in  schools  and  public  places,  the 
air  of  which  is  contaminated  with  the  specific  agent  of  the  disease. 
The  micro-organism  is  thought  to  exist  in  the  sputum  and  the  secre- 
tions of  the  nasal  and  air-passages  of  the  patient.  The  disease  is 
especially  contagious  at  the  height  of  the  attack.  There  is  reason 
to  believe  that  the  cough  of  the  first  or  catarrhal  stage  is  highly  con- 


PERTUSSIS    CONVULSIVA.  373 

tagious.  The  sputum  in  the  stage  of  decline  is  also  capable  of  convey- 
ing the  disease  to  others,  since  it  contains  the  specific  micro-organism. 

Occurrence. — Pertussis  prevails  in  all  countries  and  climates.  It 
is  most  frequent  during  the  winter  and  spring  months.  It  is  always 
endemic  in  large  cities,  but,  like  scarlet  fever,  becomes  at  times  so 
prevalent  as  to  be  epidemic.  Pertussis  is  essentially  a  disease  of 
infancy  and  childhood,  but  the  individual  is  not  exempt  at  any  age. 
I  have  met  it  in  the  newly  born  infant.  I  have  found  the  disease 
slightly  more  frequent  in  females  than  in  males  (1009  out  of  1820 
cases).  Twenty-two  cases  occurred  in  infants  between  one  and  two 
months  of  age.  The  majority  of  cases  (1343)  occurred  between  the 
sixth  month  and  the  fifth  year.  The  disease  is  most  frequent  be- 
tween the  first  and  the  second  year  (404)  ;  next  most  frequent  between 
the  sixth  and  twelfth  month.  After  the  fifth  year  the  frequency 
diminishes  up  to  the  tenth  year,  after  which  the  disease  is  very  infre- 
quent. IsTot  every  one  who  is  exposed  contracts  the  disease.  One 
attack  does  not  necessarily  confer  immunity,  but  cases  of  second 
attack  are  rare.  It  has  been  observed  that  pertussis,  measles,  and 
influenza  frequently  follow  one  another  in  epidemic  form. 

Incubation. — The  incubation  period  is  variously  placed  at  from 
two  to  fourteen  days. 

Etiology  and.  Bacteriology. — The  essential  cause  of  pertussis  was 
believed  by  Deichler  and  Kurloff  to  be  a  protozoa-like  body  which 
they  found  in  the  sputum.  Afanassjew  and  Szemetzchenko  isolated 
a  bacillus  from  the  sputum.  It  occurred  singly,  in  pairs  or  chains, 
and  measured  0.6  to  2.2  micromillimetres  in  length.  The  more 
recent  researches  on  the  bacteriology  of  pertussis  are  those  of  Czape- 
lewski,  Hensel,  and  Koplik.  Czapelewski  and  Hensel  described  in 
1897  a  non-motile  "pole  bacterium"  or  bacillus  resembling  the  in- 
fluenza bacillus.  I  at  the  same  time  described  in  the  sputum  a  finely 
punctate,  thin,  minute  bacillus,  0.8  to  1.7  micromillimetres  in  length, 
resembling  the  influenza  bacillus,  and  staining  like  that  or  like  the 
diphtheria  bacillus.  This  bacillus  was  found  recently  by  Luzatto  in 
cases  occurring  in  an  epidemic  of  pertussis  in  the  city  of  Graz.  It 
is  classified  by  him  as  belonging  to  the  influenza  group.  Positive 
proof  that  this  bacillus  is  the  cause  of  pertussis  is  lacking,  since 
the  disease  has  not  as  yet  been  produced  experimentally.  Evidence 
simply  points  toward  a  bacillus  of  the  influenza  group  constantly 
found  in  the  sputum. 

Jochmann.  and  Krause  and  Bordet  and  Gengou  have  recently 
described  a  bacillus  of  the  influenza  group  as  etiological  in  pertussis. 
It  is  probable  that  all  these  micro-organisms  are  of  the  same  class  as 
those  described  above. 

Morbid  Anatomy.- — Post-mortem  examination  reveals  marked  in- 


374  THE    SPECIFIC    INFECTIOUS    DISEASES. 

flammation  of  the  nasal  passages,  bronchopiieumoiiia,  and  empyema 
or  simple  fibrinous  or  serous  pleurisy.  Emphysema  as  a  result  of 
rupture  of  the  lung-tissues  has  been  reported  by  ISTorthrup,  who 
describes  the  lungs  of  an  infant  seven  months  old  as  being  studded 
with  cavities  measuring  one-half  a  centimetre  to  two  centimetres  in 
diameter.  The  lungs  looked  like  parchment  filled  with  bubbles. 
Hemorrhages  in  the  eye,  ear,  and  brain  are  a  feature  of  the  morbid 
anatomy  of  fatal  cases. 

Symptoms. ^ — There  is  undoubtedly  a  period  of  incubation,  but  its 
length  is  undetermined,  and  it  can  only  be  said  that,  if  the  disease 
is  due  to  the  invasion  of  a  micro-organism,  some  time  must  elapse 
between  the  invasion  and  appearance  of  symptoms.  After  the  appear- 
ance of  the  symptoms  there  are  three  stages — the  catarrhal,  the  spas- 
modic and  the  stage  of  decline.  There  is  no  sharp  line  of  demarcation 
between  these  stages. 

Catarrhal  Stage. — This  stage  in  some  children  is  characterized  by 
a  cough  which  is  especially  troublesome  at  night,  and  has  sometimes 
a  croupy  character.  The  peculiar  nature  of  the  cough  becomes 
apparent  when  after  a  few  days  it  becomes  more  troublesome  instead 
of  subsiding.  After  four  or  five  days  it  may  be  accompanied  by 
A'omiting  once  or  twice  a  day,  especiall}^  if  the  paroxysm  occurs  after 
meals.  Examination  of  the  chest  may  fail  to  reveal  bronchitis.  This 
negative  sign  is  of  great  value.  As  the  case  passes  into  the  spasmodic 
stage  it  is  noticed  that  the  paroxysms  of  coughing  last  longer,  and 
that  the  child  becomes  red '  in  the  face  and  expectorates  a  larger 
amount  of  mucus  than  in  ordinary  catarrhal  conditions.  This  period 
of  cough  without  a  whoop  may  last  five  to  twelve  days.  I  have  seen 
many  cases  in  which  the  whoop  was  absent  in  the  whole  course  of  the 
affection.  The  child  had  what  might  be  regarded  as  a  severe  spas- 
modic cough  followed  by  vomiting.  Fever  is  present  as  a  rule  only 
during  the  first  few  days.  It  may  be  remittent  and  slight.  If  bron- 
chitis complicates  this  stage  of  the  disease,  there  may  be  a  daily  rise 
of  one  or  more  degrees  in  temperature.  Usually  toward  the  close  of 
the  catarrhal  stage  the  incessant  cough  causes  slight  puffiness  of  the 
eyelids  and  slight  oedema  of  the  tissues  of  the  face. 

Spasmodic  Stage. — The  spasmodic  stage  is  distinguished  by  the 
presence  of  the  characteristic  whoop.  The  cough  becomes  of  a  more 
pronounced  spasmodic  type.  The  child  has  distinct  paroxysms, 
which  begin  with  an  insjnration,  followed  by  several  expulsive  explo- 
sive coughs,  after  which  there  is  a  deep,  long-drawn  inspiration,  which 
is  characterized  by  a  loud  crowing  called  the  whoop.  After  one 
paroxysm  has  ended,  it  may  be  followed  by  a  number  of  similar  ones. 
When  a  paroxysm  is  impending  the  face  assumes  an  anxious  expres- 
sion, and  the  child  runs  to  the  nearest  person  or  to  some  article  of 


FEBTUSSIS    CONVULSIVA.  375 

furniture  and  grasps  it  with  both  hands.  The  paroxysm  is  some- 
times so  severe  that  the  child  will  fall  prostrate  or  claw  the  air  con- 
vulsively. In  the  severest  and  most  dangerous  type  a  convulsion 
supervenes.  In  moderately  severe  types  of  the  disease  the  child's 
face  is  red  or  livid,  the  eyes  bulge,  and  at  the  end  of  the  paroxysm 
a  quantity  of  tenacious  mucoid  or  mucopurulent  sputum  is  expecto- 
rated. In  other  cases  there  is  vomiting  at  the  end  of  the  paroxysm. 
In  the  intervals  the  face  is  livid  or  pale,  or  the  eyelids  are  puffy  and 
the  face  oedematous.  In  some  cases  there  are  punctate  hemorrhages 
on  the  face,  especially  about  the  eyes  and  temples.  There  may  be 
chemosis  of  the  conjunctivae  as  a  result  of  the  bursting  of  bloodvessels. 
At  this  period  there  is  in  the  majority  of  cases  an  accompanying 
bronchitis,  with  slight  rise  of  temperature  during  the  day.  At  first 
the  paroxysms  occurring  during  the  twenty-four  hours  may  be  few; 
in  some  cases  they  never  become  frequent,  but  as  a  rule  they  increase 
in  number,  so  that  the  patient  may  have  from  twenty  to  one  hundred 
in  the  twenty-four  hours.  This  stage  gradually  declines,  the  number 
of  paroxysms  diminishing  daily  in  number  and  severity.  They  may 
subside  suddenly  or  gradually  after  from  four  to  twelve  weeks.  The 
whoop  may  at  times  reappear.  After  the  disappearance  of  the  whoop 
a  cough  persists  for  days  or  even  weeks,  or  it  may  entirely  disappear 
and  suddenly  recur  with  the  whoop.  It  is  characteristic  of  the  spas- 
modic period  of  the  disease  that  the  paroxysms  should  be  more  harass- 
ing at  night  than  during  the  day. 

Other  Sy7nptoms. — In  all  cases  of  pertussis,  even  in  the  absence 
of  complications,  there  is  a  slight  increase  in  the  number  of  respira- 
tions. In  cases  of  even  moderate  severity  the  heart  impulse  is  weak, 
and  in  exceptional  cases  the  area  of  superficial  cardiac  dulness  is 
larger  than  normal,  indicating  dilatation  of  a  moderate  degree.  The 
pulse  is  irregular  in  force  and  rhythm,  and  is  distinctly  more  dicrotic 
than  normal.  In  other  words,  there  is  a  condition  of  heart-strain, 
which  is  evinced  by  dyspnoea  (even  in  the  absence  of  exertion),  oedema 
of  the  face,  and  cyanosis. 

Kidneys. — In  the  majority  of  cases  a  trace  of  albumin  is  present 
in  the  urine;  in  others,  a  few  hyaline  casts.  Blood  in  the  urine  is 
seen  in  rare  cases. 

Blood. — Leucocytosis  of  the  polynuclear  type  is  usually  jDresent 
in  the  second  week  of  the  disease. 

Complications. — One  of  the  most  common  complications  of  per- 
tussis is  bronchitis.  It  may  be  mild  or  severe.  In  the  severer  form 
the  smaller  bronchi  are  affected,  with  accompanying  bronchopneu- 
monia (Fig.  58).  The  physical  signs  are  the  same  as  in  simple 
bronchitis  and  pneumonia  without  pertussis.  In  some  cases  the 
bronchopneumonia  pursues  a  subacute  or  persistent  course.     If  reso- 


376 


TEE    SPECIFIC   INFECTIOUS    DISEASES. 


liition  takes  place,  other  areas  become  consolidated.  Emaciatioii  is 
sometimes  extreme.  Emphysema  is  frequently  present.  Bursting 
of  the  air-vesicles  may  cause  pneumothorax,  or  air  may  escape  into 
the  mediastinum  and  thence  into  the  neck  and  into  the  subcutaneous 
tissue  of  the  whole  trunk. 

Hemorrhages. — During  a  paroxysm  there  may  be  epistaxis,  con- 
junctival hemorrhage,  bleeding  from  the  ears,  and  petechige  on  the 
face  and  body. 

Nervous  System. — Convulsions,  either  general  or  localized,  may 
complicate  pertussis.  In  the  former  case  the  outlook  is  grave,  death 
taking  place  within  twenty-four  to  forty-eight  hours. 


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Fatal  termination. 


Psychoses,  such  as  melancholia  and  hallucinations,  may  compli- 
cate pertussis.  Monoplegia,  hemiplegia,  or  paraplegia,  localized  facial 
and  oculomotor  paralyses,  sudden  total  blindness,  deafness,  cerebral 
hemorrhages,  hemiansesthesia,  and  aphasia  have  been  observed. 

Gastro-enteritis. — Gastro-enteritis  of  a  fatal  type  may  ensue. 

An  attack  of  pertussis  may  favor  the  invasion  of  the  tubercle 
bacillus.  This  may  have  been  previously  present  in  the  bronchial 
lymph-nodes  or  elsewhere  in  the  body,  or  it  may  be  received  into  the 
body  during  the  attack  or  afterward.  In  such  cases  tuberculosis  of 
the  lungs  or  other  organs,  such  as  the  peritoneum,  develops. 

Diagnosis. — If  a  cough  fails  to  improve  and  is  especially  harassing 
at  night,  later  in  the  disease  becoming  paroxysmal,  if  the  face  becomes 
livid  during  the  paroxysm,  if  the  patient  vomits  after  coughing,  per- 
tussis should  be  suspected  and  precautions  taken  to  prevent  its 
spread.     As  a  rule,  examination  of  the  chest  is  negative  in  the  first 


PERTUSSIS    CONVULSIVA.  377 

stage.  Tlie  absence  of  bronchitis  and  the  presence  of  a  cough  of  the 
character  described  are  characteristic  of  pertussis.  The  presence  of 
the  whoop  dispels  all  doubt. 

Infants  who  have  the  incisor  teeth  and  older  children  may,  after 
the  pertussis  has  lasted  for  a  week,  develop  an  ulceration  of  the 
frenum  of  the  tongue,  which  is  called  a  dentition  ulcer.  It  is  caused 
by  friction  of  the  frsenum  ling-use  with  the  edges  of  the  teeth  during 
the  act  of  coughing.  These  ulcerations  are  not  diagnostic  of  the 
disease ;  many  cases  do  not  show  them,  and  on  the  other  hand  they 
frequently  occur  in  coughs  of  other  forms. 

Mortality  and  Prognosis.- — The  mortality  of  pertussis  is  greatest 
during  the  first  year  of  life  (25  per  cent.,  Voit).  Between  the  first 
and  the  fifth  year  it  is  about  5  per  cent.,  and  from  this  time  to  the 
tenth  year,  1  per  cent.  (Monti).  The  occurrence  of  pneumonia  in 
children  under  two  years  of  age  adds  largely  to  the  mortality. 
Rachitis  or  marasmus  will  militate  against  recovery.  Hygienic  sur- 
roundings render  the  prognosis  more  favorable. 

Treatment. — Prophylaxis. — The  patient  should  be  isolated,  and 
should  sleep  in  a  large,  well-ventilated  room.  During  the  day  the 
unoccupied  sleeping-room  may  be  filled  for  an  hour  with  the  vapor  of 
formalin  (set  free  by  means  of  a  small  formalin  lamp).  The  object 
is  to  destroy  suspended  germs.  If  two  communicating  rooms  are 
available,  they  may  be  occupied  alternately  every  twenty-four  hours, 
the  unoccupied  room  being  fully  ventilated  in  the  interval.  In  this 
way  reinfection  may  be  avoided. 

In  spring  and  summer,  if  the  weather  is  favorable,  the  children 
should  be  constantly  in  the  open  air  during  the  day.  In  large  cities 
the  mother  is  directed  to  take  the  child  into  the  park.  When  in  the 
open  air  the  paroxysms  are  usually  notably  lessened.  The  child 
should  be  warmly  clad  in  winter.  Sea  air  seems  to  aggravate  some 
cases  and  benefit  others.  Pine  woods  and  moderately  high  altitudes 
are  probably  the  most  beneficial,  for  the  patients  are  not  exposed  to 
the  unfavorable  climatic  conditions  peculiar  to  the  seacoast. 

Kilmer,  to  allay  vomiting  and  the  severity  of  the  paroxysms,  has 
recently  applied  a  knitted  band  stretching  from  the  axillae  to  the 
pubes ;  on  this  is  sewn  a  width  of  silk  elastic  so  as  to  tightly  envelop 
the  abdomen.  I  have  seen  patients  quite  comfortable  with  the 
appliance. 

Medicinal  Treatment. — Medicinal  treatment  consists  of  inhala- 
tions, topical  applications,  and  internal  remedies.  Simply  to  enum- 
erate all  the  remedies  which  have  been  proposed  and  used  in  pertussis, 
would  take  up  the  space  of  a  monograph.  Inhalation  of  ozone  has 
been  advocated  by  Caille.  The  remedy  is  expensive  and  the  appa- 
ratus not  readily  procurable.     Inhalation  of  a  mixture  of  20  per 


378  TRE    SPECIFIC    INFECTIOUS    DISEASES. 

cent,  nitrous  oxide  and  80  per  cent,  oxygen  is  beneficial  in  cases  in 
which  the  heart  is  weak.  The  inhalations  are  given  with  a  cone  for 
ten  minutes  twice  daily.  Insufflation  of  quinine  or  other  drugs  has 
not  proved  beneficial.  The  practice  seemed  to  intensify  the  par- 
oxysms. Prior,  Coggeshall,  and  others  have  proposed  the  application 
of  solutions  of  cocaine,  4  per  cent,  to  10  per  cent.,  to  the  nares  and 
throat.  I  have  had  no  experience  with  this  method,  nor  with  the 
local  application  of  antitussin. 

If  the  cough  is  very  troublesome,  I  first  endeavor  to  control  it  with 
full  doses  of  antipyrin  combined  with  tincture  of  digitalis.  The 
digitalis,  in  doses  of  a  drop  or  two  several  times  daily,  supports  the 
heart,  as  is  shown  by  the  rapid  disappearance  of  the  oedema  and 
cyanosis  after  its  administration.  Antipyrin  is  given  in  doses  of 
gTain  j  (0.06)  for  every  year  of  age  up  to  grains  v  (0.3)  every  three 
hours.  If  the  cough  is  not  perceptibly  relieved  by  this  remedy  after 
forty-eight  hours,  I  suspend  its  use,  and  give  codeine  in  full  doses 
every  three  hours.  Codeine  is  to  be  preferred  to  morphine,  which  is 
advocated  by  Henoch.  If  vomiting  is  severe,  the  food  is  given  in 
very  small  quantities  in  fluid  form  every  few  hours.  By  this  method 
food  is  retained  and  absorbed,  whereas  a  full  meal  is  invariably 
rejected.  The  use  of  belladonna  has  not .  impressed  me  favorably. 
In  several  cases  it  seemed  to  aggravate  the  cough  by  causing  a  dryness 
of  the  laryngeal  mucous  membrane.  Bromoform  I  consider  danger- 
ous and  of  questionable  utility.  Quinine  in  full  doses  three  or  four 
times  daily  is  a  favorite  remedy  with  many.  Vaccination  and  the 
injection  of  diphtheria  serum  have  been  proposed  to  abort  the  dis- 
ease. I  have  had  no  experience  with  the  serum  treatment.  In  a 
word,  the  treatment  of  pertussis  consists  in  applying  the  rules  of 
hygiene,  in  mitigating  the  cough  with  antipyrin  or  preferably  codeine, 
and  in  supporting  the  heart  with  digitalis.  The  complications  should 
be  treated  on  the  principles  laid  down  in  the  sections  on  Bronchitis, 
Pneumonia,  and  Pleurisy. 

DIPHTHERIA. 

Diphtheria  is  a  contagious  febrile  disease  which  affects  the  throat 
and  air-passages.  It  is  characterized  by  the  formation  of  a  pseudo- 
membrane  on  the  parts  affected.  The  disease  manifests  itself  by  a 
local  lesion  and  general  symptoms  caused  by  the  entrance  of  toxins 
and,  at  times,  of  bacteria  into  the  blood  and  lymph. 

Age  and  Occurrence. — Although  diphtheria  is  uncommon  in  the 
newly  born  infant,  statistics  of  large  numbers  of  cases  show  a  certain 
percentage  in  these  subjects;  thus,  of  547  cases  reported  by  Monti, 
the  newly  born  number  24,  and  in  Baginsky's  statistics  several  cases 


DIPHTHERIA.  379 

are  noted.  The  disease  is  more  frequent  from  the  first  to  the  third 
month  than  from  the  third  to  the  tenth  month  (Monti).  The  largest 
number  of  cases  occur  from  the  second  to  the  sixth  year  (40  to  63 
percent.)  (Monti,  Baginsky). 

According  to  Seitz,  it  is  slightly  more  frequent  among  boys  than 
girls.  Strong  as  well  as  weakly  children  are  attacked.  Children 
who  suffer  from  nervous  affections,  such  as  poliomyelitis,  are  more 
likely  to  contract  the  disease  than  others  (Baginsky).  All  exposed 
to  infection  do  not  contract  the  disease,  because  some  individuals  are 
immune.  Escherich  and  Fischl  have  proved  that  the  blood  of  con- 
valescents contains  antitoxic  elements.  Cases  of  several  attacks  in 
the  same  individual  are  not  uncommon.  Racial  peculiarities  have 
no  influence. 

Diphtheria  is  prevalent  in  all  parts  of  the  world  and  epidemics 
occur  at  all  seasons  of  the  year.  It  is  more  common  among  the 
poorer  classes,  not  on  account  of  uncleanliness,  but  as  a  result  of 
overcrowding. 

Contagion. — Diphtheria  is  contagious  from  person  to  person,  and 
may  be  conveyed  by  any  one  who  has  been  in  the  room  occupied  by  a 
patient  with  the  disease.  Mild  cases  may  give  rise  to  fatal  cases. 
The  disease  is  infectious,  spreading  through  families  and  schools,  and 
may  be  conveyed  through  the  medium  of  sputum,  hands,  toys,  clothes, 
and  in  milk. 

Period  of  Incubation. — This  has  not  been  determined  with  any 
accuracy  in  diphtheria.  Two  to  eight  days,  or  an  average  incubation 
of  three  days,  is  laid  down  by  most  observers,  but  no  accurate  data 
are  available  on  this  important  point.  Some  authors  place  twenty 
days  as  an  extreme  limit  of  incubation.  This  latter  period  is  evi- 
dently only  founded  on  surmise. 

Etiology. ^ — The  essential  cause  of  diphtheria  is  a  bacillus,  the 
Bacillus  diphtherise,  which  was  first  noted  in  stained  specimens  by 
Klebs  in  1882;  Loffler  first  isolated  and  accurately  described  it  in 
1884.  It  is  present  in  all  cases  of  true  diphtheria  of  Bretonneau. 
In  the  3  per  cent,  of  cases  in  which  it  is  reported  absent  there  is  good 
reason  to  believe  that  failure  to  establish  its  presence  was  due  to 
imperfect  technique.  The  bacillus  is  non-motile,  twice  as  thick  and 
about  as  long  as  the  tubercle  bacillus,  thickened  at  the  extremities, 
has  no  spores,  and  in  some  forms  has  been  described  as  branching. 
It  is  very  resistant,  adheres  to  clothes  -and  candy,  and  has  been  found 
in  milk.  It  will  retain  vitality  a  long  time  in  dried  membrane 
(seventeen  weeks),  as  has  been  shown  by  Eoux  and  Yersin.  It  has 
been  detected  nine  weeks  after  the  disappearance  of  the  membrane 
from  the  throat.  It  is  found  present  with  other  bacteria,  principally 
staphylococci  and  streptococci,  pneumococci.  Bacillus  coli  commune, 


380 


TEE    SPECIFIC    INFECTIOUS    DISEASES. 


pyocaneus,  proteus,  and  sprue.  It  has  been  found  by  Roux  and 
Yersin  in  the  throats  of  perfectly  healthy  individuals,  and  may  be 
present  without  the  formation  of  a  membrane.  It  has  been  shown 
that  this  bacillus  forms  toxins  of  very  positive  action.  According  to 
Sidney,  the  toxins  of  diphtheria  may  be  divided  into  albuminoses 
and  organic  acids. 

The  pseudobacillus  of  diphtheria  was  first  isolated  by  Hoffman. 
In  its  growth  and  staining  properties  it  is  identical  with  the  true 
diphtheria  bacillus,  but  is  not  virulent  to  animals.  Roux  and  Yersin 
regard  it  as  a  weakened  diphtheria  bacillus.     Others  believe  that  it 


Fig.  59. 


Fig.  60. 


l-«»*^ 


AS 


Vrf 


'a* 


The  Bacillus  diphtheriiB    (Klebs-Lcjffler). 
Fig.  59. — ^Pure  culture,  photomicrograph.         Pig.  60\ — ^Pure  c^ilture,  photomicrograph. 
X  1000.  X  1000.     Shows  the  irregular  beaded  stain. 


bears  no  relation  to  the  true  bacillus.  It  is  found  associated  with  the 
true  bacillus,  and  also  in  cases  of  diphtheria  after  this  bacillus  has 
disappeared  from  the  throat  (Koplik).  Some  authors  have  given 
the  name  pseudodiphtheria  bacillus  to  another  variety  of  bacilli,  but 
this  term  should  be  strictly  limited  to  the  form  described  above. 

General  Infection  with  the  Bacillus  Diplitherice  alone  and  with 
Other  Bacteria. — The  bacillus  of  diphtheria  was  first  demonstrated 
by  Frosch  (1895)  in  the  heart's  blood,  liver,  spleen,  kidneys,  and 
lymph-nodes.  Since  then,  Kolisko,  Paltauf,  Schmorl,  Booker,  Coun- 
cilman, Mallory,  and  Wright  have  demonstratod  its  presence  in  the 


DIPHTHEBIA. 


381 


blood  and  internal  organs  in  fatal  cases  of  diphtheria.  The  work  of 
Councilman  and  his  pupils  is  the  most  recent  and  complete  on  this 
subject.  They  show  that  the  bacillus  may  occur  alone  or  in  associa- 
tion with  streptococci  or  staphylococci  in  the  blood,  lungs,  liver, 
spleen,  and  kidney.  It  is  more  likely  to  be  found  alone  in  fatal  cases 
of  uncomplicated  diphtheria.  The  mixed  infections  with  streptococci 
and  other  bacteria  occur  in  diseases,  such  as  scarlet  fever  and  measles, 
which  may  be  complicated  with  diphtheria.     The  investigators  just 


1  and  3.  Cultures  of  the  pseudobacillus  of  diphtheria  on  agar,  showing  the  diffuse 
character  of  the  growth.  2.  Growth  of  Bacillus  diphtheriae  (Klebs-Loffler)  on  the  same 
medium.     It  is  a  delicate  growth  in  colonies. 


mentioned  found  endocarditis,  bronchopneumonia,  empyema,  mastoid 
disease,  and  thrombosis  of  the  sinuses  due  to  the  diphtheria  bacillus. 
The  bacillus  was  found  also  in  the  pus  of  acute  abscesses  in  various 
localities. 

Morbid  Anatomy. — In  fatal  cases  the  membrane  appears  as  a 
thick  brownish  or  grayish-brown  mass.  It  is  sometimes  present  as 
a  thin  whitish  pellicle,  and  occasionally  is  almost  black.  It  may  be 
friable  or  as  resistant  as  cartilage,  and  may  extend  over  the  tonsils, 
palate,  pharynx,  base  of  tongue,  epiglottis,  and  trachea.     The  areas 


382  TBE    SPECIFIC    INFECTIOUS    DISEASES. 

not  covered  by  membrane  are  injected,  and  may  be  the  seat  of  hem- 
orrhages. The  tonsils  are  enlarged  and  blnish  red.  In  the  gan- 
grenous forms  the  tonsils,  soft  palate,  and  uvula  may  be  converted 
into  necrotic  masses.  The  nasal  j)assages  may  show  membranous 
deposit.  The  epiglottis  and  vocal  cords  are  thickened.  The  tracheal 
mucous  membrane  is  hypersemic  and  swollen,  there  may  be  adherent 
membrane,  or  the  pseudomembrane  may  be  loose  and  curled  up  in 
the  lumen  of  the  trachea. 

The  membrane  itself  has  been  described  by  Virchow  as  croupous 
and  diphtheritic.  Councilman  is  of  the  opinion  that  little  is  to  be 
gained  by  adhering  to  the  old  classification  of  croupous  and  diph- 
theritic membranes.  Baginsky  also  describes  forms  of  diphtheria  in 
which  the  membrane  possessed  both  croupous  and  diphtheritic  struc- 
tural characteristics.  According  to  Councilman,  the  first  step  in  the 
formation  of  the  membrane  is  a  degeneration  and  necrosis  of  epithe- 
lium, preceded  by  a  proliferation  of  the  nuclei  of  the  cells.  Detritus 
and  hyaline  masses  result.  An  inflammatory  exudate  rich  in  fibrin 
is  thrown  out  from  the  underlying  tissue.  '  The  fibrin  forms  in  part 
a  reticulum  enclosing  cells  and  degenerated  epithelium,  and  in  part 
a  hyaline  reticulated  membrane.  The  hyaline  membrane  is  formed 
on  surfaces  which  are  covered  with  several  layers  of  epithelial  cells. 
Fibrinous  membrane  is  formed  on  the  surface  and  in  the  tissue.  By 
constant  accretions  thick  masses  are  formed.  The  membrane  is  never 
formed  on  an  intact  epithelium,  but  may  extend  over  it.  There  is 
nothing  specific  in  the  diphtheritic  membrane.  The  connective  tissue 
and  the  bloodvessels  beneath  the  membrane  may  be  the  seat  of  hyaline 
degeneration.     The  mucous  glands  are  degenerated. 

The  diphtheria  bacilli  are  found  growing  in  the  necrotic  tissue 
and  in  the  exudation,  never  in  the  living  tissue  or  in  epithelium 
undergoing  primary  degenerative  changes.  In  exceptional  cases  they 
may  be  found  enclosed  in  pus-cells  and  necrotic  epithelium.  They 
are  found  in  masses,  and  when  deeply  situated  have  been  covered  up 
b}^  later  formation  of  membrane. 

Heart. — Councilman,  Mallory,  and  Pearce  have  recently  described 
the  myocarditis  sometimes  complicating  diphtheria.  There  is  a  fatty 
change  in  foci  or  in  more  diffuse  areas  in  the  muscle-fibre.  In  another 
form  of  myocarditis  there  are  interstitial  changes,  consisting  of  focal 
collections  of  plasma  and  lymphoid  cells,  and  the  formation  of  new 
connective  tissue,  resulting  in  some  cases  in  a  fibrous  myocarditis. 
These  pathologic  changes  are  due  to  the  action  of  the  diphtheria 
toxins  on  the  heart-muscle. 

The  Lungs. — Councilman  states  that  the  most  common  lesion  in 
fatal  cases  is  a  bronchopneumonia,  lobar  pneumonia  never  being 
present.     The  process  begins  in  an  infeclion  of  the  atria.     The  bac- 


DIPHTHERIA.  383 

teria  found  in  the  lung,  and  which  are  present  independently  of  the 
character  of  the  lesion,  are  the  pneumococcus  (rarely),  Streptococcus 
pyogenes,  and  the  diphtheria  bacillus.  Marrow-cells  are  found  in  the 
capillaries,  and'  thrombi  in  the  larger  vessels.  The  lymphatics  are 
dilated  and  contain  fibrin  and  cells. 

Spleen. — The  spleen  macroscopically  is  normal;  microscopically, 
the  lymph-nodules  are  more  prominent  than  is  normal,  and  contain 
foci  of  epithelioid  cells.  The  vessels  are  the  seat  of  hyaline  degen- 
eration, and  in  the  later  stages  contain  large  numbers  of  plasma-cells. 
Some  of  the  nodes  may  be  the  seat  of  necrosis  and  abscess. 

Liver. — The  changes  in  this  viscus  are  due  to  the  action  of  toxins, 
and  consist  of  parenchymatous  degeneration  and  necroses,  seen  espe- 
cially in  the  centre  of  the  lobules.  There  is  slight  hyaline  degenera- 
tion of  the  capillaries. 

Kidneys. — There  may  be  simple  degeneration  or  acute  nephritis. 
The  severe  forms  of  nephritis  are  found  in  the  cases  which  are  quickly 
fatal  (Councilman).  The  interstitial  and  glomerular  changes  are 
more  common  in  older  children  and  in  protracted  cases.  There  is  no 
specific  form  of  nephritis  in  diphtheria,  and  all  the  changes  are  due 
to  the  action  of  toxins. 

Lymph-nodes. — The  mesenteric  lymph-nodes,  the  nodes  at  the 
angle  of  the  jaw  and  in  the  retropharynx  and  oesophagus  are  enlarged, 
and  may  undergo  necrotic  changes  (Flexner).  Councilman,  Mallory, 
and  Pearce  describe  the  changes  in  the  lymph-nodes  as  being  more 
marked  in  those  nearest  the  lesion.  There  are  congestion,  hemor- 
rhages, and  diffuse  and  circumscribed  necrosis.  In  addition  there 
is  a  formation  of  foci  resembling  miliary  tubercles,  and  composed 
of  epithelioid  cells  which  undergo  degeneration,  forming  granular 
detritus.  Bacteria  are  not  found  in  the  nodes.  The  changes  are  due 
to  the  toxins. 

Nerves. — There  are  fibrillation,  increase  of  the  cells  of  the  sheath 
of  Schwann,  fatty  degeneration  of  the  axis-cylinder,  hemorrhages, 
and  nodular  degeneration  of  the  nerve-sheaths.  In  the  spine  there 
are  infiltration  of  the  meninges,  hemorrhages,  and  degeneration  of 
the  anterior  horns.  Degenerative  oculomotor  changes  are  present. 
There  are  dilatation  and  round-cell  infiltration  around  the  central 
canal  of  the  cord. 

Stomach. — Diphtheritic  membrane  in  the  stomach  occurring  in 
cases  of  diphtheria  has  been  described  by  Smirnow  and  Councilman. 
Of  220  cases  reported  by  the  latter,  5  showed  the  presence  of  mem- 
brane to  a  greater  or  less  extent.  The  membrane  either  covered  the 
whole  surface  or  formed  patches  or  streaks  over  the  rugse.  The 
mucous  membrane  was  swollen,  hypersemic,  or  hemorrhagic. 

The  Middle  Ear. — Of  144  cases  reported  by  Councilman,  Mai- 


384  IRE    SPECIFIC    INFECTIOUS    DISEASES. 

lory,  and  Pearce,  86  showed  involvement  of  the  middle  ear  on  one  or 
both  sides ;  in  7  the  mastoid  was  affected.  The  inflammatory  products 
were  serum  or  pus.  The  organism  most  constantly  present  was  the 
streptococcus,  but  the  diphtheria  bacillus  has  been  found,  as  have  also 
the  staphylococcus  and  pneumococcus. 

The  Blood. — The  specific  gravity  is  increased  at  the  height  of  the 
disease.  In  mild  cases  it  is  not  perceptibly  changed ;  in  severe  septic 
cases  it  may  range  from  1054  to  1060  (Baginsky).  Haemoglobin  is 
reduced  only  in  severe  cases  of  protracted  course.  Leucocytosis  is 
not  marked  in  mild  cases,  but  in  severe  septic  forms  an  increase  of 
the  white  blood-cells  has  been  observed  by  Felsenthal  and  Monti,  In 
malignant  cases  there  is  a  reduction  in  the  number  of  red  blood-cells 
(Ewing,  Billings,  Morse). 

Sjrmptoms. — Clinically,  it  is  convenient  to  divide  diphtheria  into 
the  purely  local  forms  with  few  constitutional  symptoms,  the  local 
forms  with  symptoms  of  marked  toxaemia  or  septic  forms,  and  the 
laryngeal  forms. 

Purely  Local  Forms  ivith  Slight  C otistitutioiial  Disturbances. — 
In  diphtheria  sine  membrana,  cynanche  contagiosa  (Senator),  or 
catarrhal  diphtheria,  there  may  be  no  formation  of  membrane,  the 
fauces  showing  only  an  angina  of  varying  severity.  In  some  cases 
there  is  the  picture  of  a  follicular  or  lacunar  amygdalitis.  Macro- 
scopically  there  is  nothing  to  show  that  the  process  is  diphtheritic 
(Plate  XXIII. ) .  In  other  forms  the  membrane  is  present  on  the  tonsils 
as  specks  or  strips  of  exudate,  or  white  or  greenish  pultaceous  masses 
which  may  extend  to  the  uvula,  or  there  may  be  spots  or  extensive 
plaques  on  the  posterior  pharyngeal  wall.  In  other  mild  cases  the 
process  is  confined  to  a  small  necrotic  excavated  area  in  one  or  the 
other  tonsil,  as  described  by  Henoch.  In  still  other  forms  the  mem- 
brane may  cover  both  tonsils,  and  extend  over  the  soft  palate  and 
pillars  of  the  fauces.  In  these  forms  of  localized  diphtheria  the  nares 
are  seldom  involved. 

In  these  localized  forms  of  diphtheria  the  infant  or  child  may 
present  few  symptoms  pointing  to  the  throat  affection.  Unless  the 
physician  be  systematic  in  his  methods  of  examination,  he  may  fail 
to  inspect  the  throat  at  his  first  visit,  and  the  diphtheria  may  thus 
escape  detection.  The  nursling  in  this  as  in  the  non-diphtheritic 
affection,  may  refuse  to  take  the  breast.  The  movements  are  green- 
ish, and  have  an  offensive  odor,  or  may  be  diarrhceal.  There  are 
fever  and  restlessness.  Inspection  will  reveal  slight  or  marked  swell- 
ing of  the  lymph-nodes  at  the  angle  of  the  jaw.  The  temperature 
may  not  be  above  101°  F.  (38.3°  C.)  or  may  be  as  high  as  105°  F. 
(40.5°  C).  As  a  rule,  it  is  not  persistently  high.  The  pulse  is 
accelerated  and  the  respirations  slightly  increased. 


PLATE    XXIII 


1.     Tonsillar  Diphtheria,  ^A/^ith  a  small    patch  of  membrane 

on  the  uvula. 
2.     Tonsillar  Diphtheria,  with  a  patch  of  membrane  on  the 

pillars  of  the  fauces. 
8.     Acute  Follicular  Amygdalitis,  which  may  be  diphtheritic. 


DIPHTHEBIA.  385 

The  invasion  of  the  disease  is  for  the  most  part  insidious  in 
nurslings;  rarely  is  there  a  chill  or  convulsion.  The  tonsils  are  en- 
larged, and  show  small  specks  or  plaques  of  membrane  on  their  sur- 
face. The  uvula  may  be  red  and  swollen,  and  there  may  be  patches 
of  membrane  on  the  sides  adjacent  to  the  tonsils.  There  is  sometimes 
a  croupy  cough.  In  purely  local  diphtheria,  however,  the  larynx  is 
not  involved  in  the  majority  of  cases.  The  urine  may  show  a  trace 
of  albumin,  and  in  some  cases  a  few  leucocytes,  blood-cells,  and  a 
very  few  hyaline  casts.  In  older  children  the  signs  of  illness  are 
more  marked.  They  complain  of  pain  on  swallowing,  and  the  tem- 
perature may  at  first  be  high.  Toxsemic  symptoms,  such  as  pain  in 
the  joints,  headache,  pain  in  the  back,  and  slight  prostration,  are 
present.  Inspection  of  the  throat  may  show  the  tonsils  to  be  enlarged, 
and  to  present  the  appearances  mentioned  above.  Other  members  of 
the  family  may  complain  of  sore  throat.  I  have  reported  cases  in 
which  children  complained  of  but  few  symptoms  and  engaged  in  their 
customary  play.  Examination  of  their  throats  disclosed  the  presence 
of  simple  inflammatory  redness  and  swelling  of  the  tonsil,  pharynx, 
and  uvula.  In  these  cases  the  diphtheria  bacillus  was  detected  in 
scrapings  from  the  fauces.  Membrane  never  developed,  and  yet  they 
were  cases  of  true  diphtheria. 

The  fever  is  not  characteristic.  The  temperature  may  at  first 
reach  104°  F.  (40°  C.)  or  above,  and  gradually  drops  to  the  normal 
with  subsidence  of  the  symptoms.  Otitis  and  suppuration  of  the  sub- 
maxillary and  retropharyngeal  lymph-nodes  may  cause  the  tempera- 
ture to  become  remittent  or  intermittent. 

Septic  Form  of  Diphtheria. — In  the  second  clinical  form  of 
diphtheria  there  are  in  addition  to  the  local  symptoms  present  in 
the  first  form,  constitutional  symptoms  of  a  severe  or  even  septic  type. 
The  children  at  the  outset  appear  very  ill;  the  temperature  is  high, 
there  is  marked  restlessness  with  a  tendency  to  drowsiness,  the  face 
is  flushed,  and  the  breathing  noisy  or  nasal.  The  infants  refuse  the 
breast  or  bottle,  and  older  children  complain  of  great  pain  in  swal- 
lowing. In  some  cases  the  glands  at  the  angle  of  the  jaw  are  swollen, 
and  the  neck  is  more  rotund  than  normal.  Inspection  of  the  throat 
shows  the  membrane  on  the  tonsils,  or  on  both  uvula  and  tonsils.  It 
spreads  rapidly,  the  tonsils,  soft  palate,  and  pharynx  being  covered 
in  one  or  two  days.  The  membrane  may  break  down,  and  masses  of 
necrotic  tissue  be  expectorated.  In  severer  forms  the  membrane 
extends  over  the  posterior  nares,  and  gradually  invades  the  nasal  pas- 
sages. At  first  a  slight  nasal  serous  discharge  is  noticed,  which  in- 
creases in  amount  and  becomes  ichorous  and  tinged  with  blood;  the 
anterior  nares  become  eroded  and  are  coated  with  a  whitish  or  greenish 
membrane.     In  some  cases  the  membrane  involves  the  buccal  mucous 

25 


386  TEE    SPECIFIC    IXFECTIOrS    DISEASES. 

membrane.  There  is  severe  stomatitis,  the  lips  are  eroded,  and  the 
angles  of  the  mouth  may  show  rhagades  covered  with  membrane. 
With  the  development  of  these  symptoms  the  toxaemia  increases ;  the 
fever  may  be  moderate,  not  exceeding  102°  or  103"  F.  (38.8°  or 
39.4°  C.)  ;  the  pulse  is  rapid  and  feeble;  the  sensorium  somewhat 
benumbed.  The  lymph-nodes  at  the  angle  of  the  jaw  may  be  much 
enlarged,  and  the  tissue  underneath  the  jaw  may  be  the  seat  of  phleg- 
monous inflammation.  The  breath  has  a  very  fetid  odor.  The  urine 
may  reveal  the  presence  of  albumin,  a  slight  amount  of  blood,  and  a 
few  casts  of  the  hyaline  or  epithelial  type. 

The  constitutional  symptoms  may  diminish  in  severity,  and  with 
the  subsidence  of  the  local  symptoms  the  appetite  returns,  the  sen- 
sorium brightens,  and  recovery  gradually  takes  place.  On  the  other 
hand,  if  a  fatal  issue  occurs,  it  results  from  heart  paralysis,  paralysis 
of  the  general  nervous  system  and  respiratory  function,  or  extension 
of  the  diphtheritic  process  to  the  larynx,  trachea,  and  lungs. 

If  the  diphtheria  extends  to  the  larynx,  the  voice  becomes  first 
husky,  then  croupy.  The  breathing  is  labored  and  of  the  laryngeal 
or  croupy  types,  there  is  retraction  of  the  suprasternal  notch  and  epi- 
gastrium, the  accessory  muscles  of  respiration  are  drawn  into  play, 
and  unless  relieved  the  patient  dies  of  suffocation.'  Even  if  relieved, 
when  the  septic  symptoms  and  toxaemia  are  severe  the  patient  may 
succumb  or  the  process  may  spread  downward,  and  involve  the  trachea 
and  lungs.  In  those  cases  in  which  there  is  cardiac  paralysis,  vom- 
iting and  abdominal  pain  supervene.  The  patient  is  pale  and  the 
surface  cool.  Gallop  rhythm  sets  in  and  the  heart-sounds  become 
indistinct.  The  expression  is  at  first  anxious,  then  apathetic ;  the 
voice  is  scarcely  audible;  the  patients  no  longer  notice  their  sur- 
roundings. Death  ensues  from  pulmonary  cedema  with  symptoms  of 
heart-failure. 

If  the  general  nervous  system  is  involved,  paralysis  of  the  soft 
palate  sets  in  even  after  the  membrane  has  disappeared  from  the 
tonsils  and  pharynx.  The  reflexes  are  absent,  and  the  child  is  unable 
to  sit  upright.  The  act  of  swallowing  not  only  becomes  difficult,  but 
fluids  may  find  their  way  into  the  larynx  and  thence  into  the  trachea, 
causing  pneumonia ;  or  the  paralysis  may  extend  to  the  diaphragm, 
when  the  lethal  issue  is  hastened  by  paralysis  of  the  respiratory 
apparatus. 

The  Malignant  Septic  Form. — This  form  has  been  partly  de- 
scribed above.  It  is  characterized  not  only  by  the  malignancy  of  the 
local  process,  but  by  the  severity  of  the  toxsemic  symptoms  as  well. 
It  was  formerly  believed  that  these  cases  were  due  to  mixed  infections 
with  streptococci  and  staphylococci,  but  it  is  now  known  that  the 
Bacillus  diphtheriae  alone  may  cause  all  the  symptoms.     In  these 


DIPETHEEIA.  387 

cases  not  only  the  toxins,  but  the  bacillus  itself  enters  the  circu- 
lation. The  pharynx,  tonsils,  and  nares  are  covered  with  a  dirty 
brown  or  greenish  membranous  exudate.  There  is  an  ichorous  dis- 
charge from  the  nares.  The  tonsils,  pharynx,  and  lymph-nodes  of 
the  neck  become  necrotic.  The  membrane  is  discharged  from  the 
nose  and  mouth.  The  fetor  of  the  breath  is  extreme,  and  the  pros- 
tration correspondingly  great.  The  larynx,  trachea,  and  lungs  may 
be  involved  in  the  diphtheritic  process.  The  pulse  is  weak  and  rapid. 
The  temperature  may  not  be  above  the  normal,  and  in  some  cases 
may  be  subnormal.  Acute  nephritis  may  be  present.  In  some  cases 
hemorrhage  under  the  skin  and  from  the  nose,  mouth,  bowel,  and  even 
kidney,  may  precede  death. 

A  few  cases  recover,  but  in  them  the  necrosis  of  tissue  in  the 
pharynx  and  larynx  causes  permanent  defects  and  cicatricial  con- 
tractures. Loss  of  the  uvula  and  perforations  of  the  soft  palate  may 
result  from  diphtheria  in  early  life. 

Laryngeal  Diphtheria. — Laryngeal  diphtheria  (croup)  is  the  re- 
sult of  the  extension  of  a  mild  or  severe  tonsillar  or  pharyngeal  diph- 
theria. There  may  be  no  preceding  clinical  manifestations.  There 
are  the  rare  cases  of  so-called  ascending  croup,  whose  existence  has 
not  been  wholly  disproved.  Cases  are  seen  in  which  the  most  careful 
inspection  has  failed  to  detect  preceding  disease  of  the  pharynx,  epi- 
glottis, or  tonsils.  Lastly,  there  is  a  class  of  cases  which  occurs 
during  convalescence  from  pharyngeal  or  tonsillar  diphtheria. 

The  symptoms  vary  accordingly  as  the  disease  manifests  itself 
first  in  the  larynx  or  follows  a  localized  tonsillar  or  pharyngeal  diph- 
theria. In  the  latter  case  there  may  be  slight  redness  of  the  tonsils 
or  pharyngeal  mucous  membrane,  or  the  parts  above  the  larynx  may 
show  membranous  deposits.  In  either  case  the  laryngeal  invasion 
is  ushered  in  by  croupy  cough  and  stridulous  or  metallic  breathing. 
The  cough  is  harassing  and  persistent,  and  the  stridor  increases  within 
twenty-four  or  forty-eight  hours  to  such  an  extent  as  to  be  distinctly 
audible,  and  to  give  the  impression  that  there  is  a  mechanical  obstruc- 
tion in  the  larynx.  The  breathing  becomes  labored,  and  there  is 
retraction  of  the  parts  above  the  sternum  and  of  the  peripneumonic 
groove,  especially  at  the  epigastrium.  In  rachitic  infants  the  sides 
of  the  chest  and  the  epigastrium  are  markedly  retracted  at  each  descent 
of  the  diaphragm.  With  increasing  obstruction  the  face  assumes  an 
anxious  expression,  the  lips  become  cyanosed,  and  the  surface  cool. 
The  pulse  is  rapid — 120  to  180.  The  fever  may  be  high  or  low. 
The  lividity  of  the  face  in  the  severer  forms  of  dyspnoea  gives  place 
to  pallor.  The  picture  of  laryngeal  obstruction,  with  the  stridulous 
breathing,  increased  respirations,  and  overaction  of  the  accessory 
muscles  of  respiration,  is  so  characteristic  as  to  be  significant  to  even 


388  THE    SPECIFIC    IXFECTIOrS    DISEASES. 

the  inexperienced  observer.  During  the  paroxysms  of  coughing 
membranous  casts  are  expelled  from  the  larynx.  The  membrane 
may  extend  downward,  involving  the  trachea  and  bronchi,  casts  of 
which  may  be  expelled.  The  lungs  may  become  involved,  and  in 
severe  cases  are  the  seat  of  a  bronchopneumonia  of  streptococcic 
nature.  With  this  there  may  be  compensatory  emphysema.  The 
urine  may  show  the  existence  of  slight  or  extensive  nephritis,  or  may 
be  normal  in  every  respect. 

Especially  deceptive  are  those  cases  of  membranous  laryngeal 
diphtheria  or  croup  whose  onset  closely  resembles  that  of  so-called 
catarrhal  laryngitis.  In  these  the  symptoms  may  develop  suddenly, 
and  within  twenty-four  hours  the  patient  presents  all  the  symptoms 
of  laryngeal  obstruction  (croup  d'emblee  of  the  French).  Inspec- 
tion may  show  little  variation  from  the  normal  appearances  in  the 
pharynx.  We  should  be  cautious  not  to  assume  that  no  membrane 
is  present  in  the  larynx.  Cases  have  been  recorded  in  which  laryn- 
goscopic  examination  failed  to  show  membrane  in  the  larynx,  but 
in  which  postmortem  it  was  found  beneath  the  cords  and  in  the 
trachea. 

Course  and  Duration. — In  the  mildest  and  purely  local  forms  the 
disease  reaches  its  height  in  from  two  to  four  days;  the  temperature 
then  drops  to  the  normal  and  convalescence  is  established  In  the 
severe  septic  forms  the  membrane  spreads  from  the  tonsils  to  the 
pharynx,  and  the  disease  attains  its  full  development  in  from  five  to 
eight  days.  The  temperature  falls  by  lysis  or  crisis,  and  convales- 
cence is  established.  If  the  case  is  very  severe,  the  disease  shows  no 
tendency  to  limit  itself,  the  toxsemia  is  extreme  and  the  involvement 
of  the  lymph-nodes  is  very  great.  Death  may  enstte  in  from  a  week 
to  fourteen  days.  In  some  very  malignant  cases  death  may  ensue  in 
from  three  to  four  days  after  the  onset  of  the  disease.  The  laryngeal 
diphtheritic  croup  reaches  its  full  development  as  a  rule  early — 
within  three  days.  The  disease  may  then  retrograde  under  treat- 
ment or  may  advance  into  the  trachea  and  bronchi,  and  cause  death 
in  a  variable  length  of  time. 

Complications. — The  complications  include  bronchopneumonia, 
pleuritis,  gastro-enteritis.  retropharyngeal  abscess,  suppuration  or 
necrotic  destruction  of  the  lymph-nodes  of  the  neck,  nephritis,  cardiac 
paralysis,  early  and  late  for  post-diphtheritic)  general  paralysis,  and 
diphtheria  of  the  eyes,  skin,  and  vulva. 

Bronchopneumonia  and  Pleuritis. — Bronchopneumonia  is  found 
in  from  50  per  cent.  (Baginsky)  to  80  per  cent.  (Talamon)  of  the 
autopsies  on  children  who  have  died  of  diphtheria.  It  results  from 
extension  of  the  disease  from  the  trachea  into  the  smaller  bronchi  and 
alveoli  of  the  lung,  and  is  therefore  always  a  true  bronchopneumonia. 


DIPETHEBIA.  389 

Through  the  investigations  of  Loffler,  Flexner,  ISTorthrup,  and  Prud- 
den,  it  has  been  proved  that  the  diphtheria  bacillus,  the  Streptococcus 
pyogenes,  the  Staphylococcus  pyogenes,  and  the  pneumococcus  are  the 
exciting  causes  of  the  pneumonia.  In  the  pneumonia  resulting  from 
the  diphtheritic  or  pseudodiphtheritic  processes  complicating  scarlet 
fever  and  measles,  Prudden  and  ISTorthrup  have  shov^n  that  the  Strep- 
tococcus pyogenes  is  an  active  causal  agent.  The  onset  of  a  compli- 
cating pneumonia  is  generally  indicated  by  an  exacerbation  of  the 
dyspnoea,  fever,  and  cough.  The  prostration  is  also  more  marked. 
Auscultation  of  the  inferior  lateral  or  posterior  parts  of  the  chest  on 
one  or  both  sides  reveals  the  presence  of  bronchopneumonia;  while 
resolution  is  taking  place  in  one  part  of  the  lung,  other  areas  are  being 
involved.  Thus  an  apparent  improvement  may  be  follow^ed  by  a 
rapid  rise  of  temperature,  increased  dyspnoea,  and  rapid  pulse.  This 
form  of  bronchopneumonia  may  be  complicated  by  pleuritis  of  a 
serous,  serofibrinous,  purulent,  or  hemorrhagic  type. 

Gastro-enteritis. — In  nurslings  there  is  frequently  a  diarrhoea 
v^ith  green  stools  and  vomiting.  In  some  cases  these  symptoms  may 
become  severe.  Extension  of  the  membrane  into  the  oesophagus, 
stomach,  and  gut  may  take  place,  v^ith  a  fatal  result.  The  cases  of 
simple  diarrhoea  are  directly  due  to  the  swallov^^ing  of  bacteria  from 
the  mouth  and  fauces.  The  diarrhoea  may  be  so  severe  as  to  become 
one  of  the  leading  features  of  the  disease. 

Retropharyngeal  Abscess. — Retropharyngeal  abscess  occurs  in  the 
tonsillar  and  pharyngeal  forms  of  diphtheria  as  a  result  of  infection 
of  the  retropharyngeal  lymph-nodes  by  streptococci. 

Nephritis. — ISTephritis  may  be  absent,  slight,  or  severe.  Baginsky 
found  it  present  in  42  per  cent,  of  his  cases.  In  the  majority  of  cases 
of  even  mild  diphtheria  there  is  albuminuria ;  in  some  the  urine  may, 
in  addition,  contain  casts,  blood-cells,  renal  epithelium,  and  leucocytes, 
shoM^ing  grave  lesions  of  the  kidneys. 

The  affection  of  the  kidneys  is  brought  about  by  the  action  of 
the  toxins  on  the  parenchyma  of  the  kidney.  ISTot  only  are  toxins 
produced  in  the  kidney  substance,  but  bacilli  have  been  found  in  the 
kidney  and  in  the  urine.  A  large  percentage  of  the  cases  of  nephritis 
are  of  the  mild  type.  Here,  as  in  scarlet  fever,  v^^e  have  cases  in 
vs^hich  there  is  nephritis  with  blood-casts  and  ursemic  symptoms  in  the 
course  of  the  disease,  and  cases  in  which  there  is  total  suppression. 
All  are  agreed  that  oedema  and  anasarca  of  the  body  are  uncommon, 
even  in  the  presence  of  severe  nephritis.  I  have  seen  severe  septic 
forms  of  pharyngeal  diphtheria  ushered  in  with  vomiting  and  ursemic 
symptoms,  such  as  headache  and  exhaustion,  before  the  appearance 
of  the  membrane.  These  symptoms  subsided  when  the  membrane 
was  fully  formed,  to  be  followed  in  a  few  days  by  complete  suppres- 


o90  TRE    SFECIFIC    INFECTIOUS    DISEASES. 

sion  of  urine  after  the  disappearance  of  the  membrane.  In  one  of 
my  cases  the  membrane  had  entirely  disappeared  from  the  throat  and 
the  patient  was  apparently  convalescing  when  total  suppression  set 
in,  continued  for  several  days,  followed  by  uremic  convulsions  and 
death. 

Heart  Paralysis. — Of  greatest  clinical  significance  is  the  cardiac 
diphtheritic  paralysis,  which  may  become  apparent  either  early  in 
the  disease  or  later  on  in  convalescence.  The  early  form  may  set  in 
while  the  membrane  is  still  visible  in  the  throat.  It  occurs  in  the 
septic  forms  of  the  disease.  These  are  the  severe  cases.  The  chil- 
dren show  great  prostration  and  apathy;  the  pulse  is  rapid  and 
irregular ;  the  heart-sounds,  especially  the  muscular  sounds,  are  indis- 
tinct; the  pulse  is  feeble  and  flickering;  there  are  vomiting  and 
abdominal  pain. 

These  symptoms  may  repeat  themselves  in  attacks,  until  finally 
the  patient  dies  with  all  the  symptoms  of  collapse,  such  as  cool  ex- 
tremities and  shallow  respirations.  In  such  cases  there  is,  as  a  rule, 
a  marked  nephritis.  In  the  late  cases  the  symptoms  of  cardiac  failure 
appear  from  the  second  week  of  the  disease  to  the  seventh  week  of 
the  convalescence.  The  membrane  has  disapjieared  from  the  throat. 
There  may  be  no  premonitory  symptoms,  or  there  may  have  been  a 
slight  blowing  murmur  at  the  apex.  In  their  mildest  form  the  heart 
symptoms  appear  in  the  second  or  third  week.  The  heart  becomes 
irregular,  and  the  muscular  sound  is  weak ;  the  pulse  becomes  small 
and  either  slow  or  rapid  (tachycardia).  There  may  be  attacks  of 
syncope,  during  which  the  patients  vomit,  complain  of  abdominal 
pain,  and  refuse  medicine  and  nourishment.  Sudden  cardiac  failure 
and  death  without  symptoms,  premonitory  or  otherwise,  may  occur  in 
the  period  of  convalescence. 

Mild  forms  of  cardiac  irregularity  which  do  not  eventually  prove 
fatal  are  seen  in  the  beginning  of  convalescence.  There  are  forms 
of  cardiac  irregularity  which  may  appear  alarming  at  first  and  in 
which  complete  recovery  results.  Thus,  as  will  be  seen  under  the 
heading  of  Myocarditis,  it  is  not  uncommon  in  the  convalescence, 
early  or  late,  to  observe  the  heart  become  irregular.  This  irregu- 
larity increases  from  day  to  day.  In  its  most  pronounced  form  I 
have  observed  it  in  a  child  three  years  of  age,  in  whom  the  heart 
would  contract  two  or  three  times,  there  would  then  be  a  pause,  fol- 
lowed by  a  two  or  three  or  four  contractions.  The  pulse  vfiried  from 
80  to  96  during  sleep,  and  110  to  130  in  the  waking  state.  The 
compressibility  of  the  pulse  varies  in  these  cases;  the  heart-beat  is 
weak,  or  at  times  may  be  strong.  The  second  sound  will  be  accen- 
tuated at  the  pulmonary  orifice.  In  these  cases  the  child  is  apparently 
comfortable.      There   is  no  pericardial    distress,   pain. 


DIPHTHEEIA.  391 

there  maj  be  occasional  sighing.  The  cardiac  irregularity  may  per- 
sist for  days,  even  weeks,  and  ultimate  recovery  result.  It  is  not 
always  in  the  severe  cases  of  diphtheria  that  these  symptoms  of  car- 
diac disturbance  appear,  but  often  in  the  apparently  mild  cases  of 
short  duration. 

The  severe  forms  of  cardiac  paralysis  set  in  with  symptoms  of 
the  early  cases.  These  symptoms  may  have  been  preceded  by  the 
milder  symptoms  of  cardiac  irregularity.  There  is  slight  albumi- 
nuria. Suddenly,  while  in  apparent  good  health,  the  patients  com- 
plain of  dyspnoea  and  pain  in  the  stomach.  The  lips  become  cyanosed 
and  the  extremities  cool,  the  pulse  thready,  the  heart  impulse  weak, 
the  heart-sounds  scarcely  audible;  the  heart  may  be  rapid  or  as  slow 
as  40  to  50  beats  per  minute.  Vomiting  is  repeated,  and  in  some 
cases  the  liver  is  enlarged,  as  also  the  spleen.  In  all  cases  of  diph- 
theritic myocarditis  the  enlargement  of  the  liver  and  spleen  with  the 
increase  of  the  pulse  rate  is  a  symptom  of  very  serious  moment,  and, 
as  a  rule,  a  precursor  of  a  fatal  issue.  The  patients  may  survive  one 
or  two  such  attacks,  only  to  succumb  finally.  In  the  early  forms  of 
cardiac  paralysis  there  may  be  no  gross  lesions  in  the  heart-muscle. 
In  the  later  forms  the  lesions  are  more  apparent.  There  are  fatty 
parenchymatous  changes.  In  other  cases  there  may  in  addition  be 
changes  in  the  vagi. 

Diphtheritic  Paralyses. — Paralyses  are  the  result  of  the  action  of 
the  toxins  of  the  Bacillus  diphtherise  on  the  nerve-trunks  and  tissues 
of  the  general  nervous  system.  The  paralysis  may  occur  in  the  course 
of  the  disease  or  during  convalescence.  When  the  paralysis  occurs 
early,  it  affects  the  velum  pendulum  palati.  In  cases  which  result 
fatally  the  heart  becomes  affected,  pneumonia  caused  by  the  passage 
of  food  into  the  larynx  develops,  or  the  paralysis  may  become  general. 
In  the  latter  case  the  symptoms  are  similar  to  those  seen  in  the  post- 
diphtheritic forms  of  paralysis.  This  form  of  paralysis  manifests 
itself  from  the  second  to  the  sixth  week  after  the  onset  of  the  disease. 
In  mild  forms,  it  may  begin  with  a  paralysis  of  the  muscles  of  the 
soft  palate,  which  remains  localized.  The  child  has  a  nasal  tone  of 
voice,  and  liquid  food  is  regurgitated  through  the  nose  on  swallowing. 
In  severe  cases  there  are  in  addition  loss  of  the  patellar  reflexes,  ataxic 
conditions,  inability  to  sit  upright  or  to  stand,  oculomotor  paralysis, 
facial  paralysis,  pallor,  weak  heart,  arrhythmia,  loss  of  appetite,  and 
albuminuria. 

Recovery  may  take  place  even  when  there  is  general  involvement 
of  the  muscles.  The  great  danger  is  extension  of  the  paralysis  to  the 
diaphragm."  Post-diphtheritic  paralysis  occurs  in  5  to  7  per  cent,  of 
the  cases  of  diphtheria,  according  to  Baginsky,  who  reported  131 
cases  of  paralysis  in  2300  cases  of  diphtheria.     The  soft  palate  was 


392  THE    SPECIFIC   INFECTIOUS   DISEASES. 

most  often  affected.  Among  the  other  forms  of  paralysis  are  those 
of  the  facial  and  oculomotor  nerves,  the  larynx  (recurrent  laryngeal), 
and  lastly  forms  of  ataxia.  Antitoxin  has  little  effect  in  preventing 
these  paralyses.  They  occur  as  frequently  after  its  administration 
as  during  the  pre-antitoxin  period. 

In  the  American  Pediatric  Society's  tabulation  9.7  per  cent,  of 
the  cases  had  paralysis;  of  these,  32  out  of  a  total  of  328  cases  died 
of  cardiac  paralysis. 

Hemiplegic  cerebral  palsy  may  occur  in  diphtheria  (Monti,  Levi, 
Baginsky) . 

Disturbances  of  the  Sensory  Nerves. — Disturbances  of  the  sensory 
nerves  also  occur  in  diphtheria,  such  as  perversions  of  the  senses  of 
smell  and  taste ;  also  anaesthesia  of  the  rectum. 

Psychical  Derangements. — Psychical  derangements  such  as  mel- 
ancholia have  been  reported. 

Diphtheritic  Ophthalmia. — True  diphtheritic  ophthalmia  occurs 
both  as  an  accompaniment  of  diphtheria  of  the  fauces  and  as  a  pri- 
mary affection.  There  are  two  distinct  forms  of  pseudomembranous 
affection  of  the  eye.  In  the  first,  the  Loffler  bacillus  is  present,  but 
in  the  second,  or  diphtheroid  form,  it  is  absent,  and  the  streptococcus 
alone  is  found.  Of  the  true  diphtheritic  form,  one  class  of  cases  has 
a  mild  clinical  course.  In  these  the  bacillus  isolated  resembles  the 
pseudodiphtheria  bacillus  in  not  possessing  virulent  properties.  In 
the  other  form  of  diphtheritic  eye  affection  the  membrane  spreads 
rapidly  and  causes  destruction  of  the  eye. 

The  dii)htheritic  invasion  is  ushered  in  vrith  redness  and  chemosis. 
The  membrane  appears  first  on  the  palpebral  conjunctiva,  and  causes 
marked  swelling  of  the  lids.  There  is  little  seropurulent  discharge. 
In  the  progressive  form  destruction  and  perforation  of  the  cornea 
result.  I  have  seen  several  cases  in  connection  with  fatal  diphtheria 
complicating  measles,  and  also  cases  in  which  there  was  no  history 
of  diphtheria  in  the  patient  or  family.  I  have  seen  it  occur  as  a 
primary  affection  in  nurslings.  According  to  Baginsky,  diphtheritic 
ophthalmia  occurs  in  3  per  cent,  of  the  cases  of  diphtheria,  and  is 
most  frequent  from  the  second  to  the  sixth  year. 

Diphtheria  of  the  Skin. — Diphtheria  of  the  skin  occurs  when  the 
specific  bacillus  finds  lodgment  in  an  abrasion  or  cut.  The  mem- 
brane spreads  over  the  wound  and  encroaches  on  the  surrounding  skin. 

Diphtheria  of  the  Vulva. — Diphtheria  of  the  vulva  is  met  with 
both  as  a  primary  affection  and  as  a  complication  of  true  diph- 
theria elsewhere  in  the  body.  I  have  not  found  the  Klebs-LofQer 
bacillus  in  a  number  of  pseudomembranous  inflammations  of  the 
vulva  and  vagina  in  infants.  Some  of  these  cases  show  the  presence 
of  true  membrane ;  others  begin  as  aphthous  ulceration  and  develop 


DIFRTHEBIA.  393 

membrane  later.  These  cases  are  benign.  Tbe  diphtheritic  bacil- 
lary  cases  may  be  divided  into  two  distinct  classes  according  to  their 
causation.  The  cases  of  one  class  show  the  Loffler  bacillus,  but  are 
benign  in  course,  although  I  have  proved  by  animal  experiment  the 
presence  of  the  bacillus  of  diphtheria  in  virulent  form.  In  the  other 
class  of  cases  there  is  extensive  destruction  of  tissue,  and  sometimes  a 
fatal  result.  Cases  of  this  class  occur  as  a  complication  of  diphtheria 
elsewhere  in  the  body  or  in  connection  with  the  exanthemata. 

The  symptoms  of  diphtheria  of  the  vulva  and  vagina  may  be 
localized  strictly  to  the  parts,  or  there  may,  as  in  the  severer  forms, 
of  Henoch,  be  constitutional  symptoms  of  toxaemia.  Locally,  the  dis- 
ease is  characterized  by  the  appearance  of  patches  of  membrane  on 
the  inner  surface  of  the  labia,  clitoris,  and  introitus  vaginge.  The 
parts,  especially  the  labia  majora,  are  intensely  swollen  and  (Edema- 
tous. In  Henoch's  cases  there  was  gangrene  or  necrosis  of  neighbor- 
ing tissues.  In  my  cases  there  was  no  complicating  diphtheria  of 
other  parts.  The  cases  occurred  in  infants  and  in  children  under  two 
years.     They  were  benign  in  course,  although  of  bacillary  type. 

Nasal  Passages. — Councilman,  Mallory,  and  Pearce  call  attention 
to  the  frequency  of  invasion  of  the  accessory  sinuses  of  the  nose  and 
antrum  by  the  diphtheritic  process.  They  found  the  antrum  affected 
in  33  cases  of  52  examined.  Clinically,  this  affection  is  more  com- 
mon than  appears  from  these  figures.  This  would  account,  according 
to  these  authors,  for  the  persistence  with  which  diphtheria  bacilli 
continue  in  the  nasal  secretions  after  the  throat  lesions  have  disap- 
peared. The  disease  of  the  antrum  may,  as  pointed  out  by  Wolff, 
and  recently  by  Mayer,  persist  after  the  diphtheria  has  run  its  course. 
Mayer  classifies  the  symptoms  as  eversion  of  the  lower  lid,  fistulous 
opening  in  the  cheek  from  which  pus  exudes,  and  a  fetid  purulent 
discharge  from  the  nose  on  the  side  of  the  face  at  which  the  fistula 
is  situated. 

Other  Complicatio7is, — Diphtheria  in  pertussis  is  a  serious  com- 
plication, since  the  resistance  of  the  patient  is  generally  much  de- 
creased. Bronchopneumonia  is  especially  to  be  feared.  In  tuber- 
culosis the  patient  usually  dies  as  a  direct  result  of  the  complication. 
In  measles  the  diphtheritic  process  is  a  grave  complication;  it  may 
invade  the  larynx  and  death  may  ensue  from  extension  of  the  disease 
to  the  lungs.  In  typhoid  fever  the  process  causes  death  by  invasion 
of  the  lungs. 

Exanthem.^ — Is  there  an  exanthem  characteristic  of  diphtheria  ? 
I  am  inclined  to  view  all  eruptions  which  may  occur  in  the  course  of 
this  disease  as  purely  accidental.  They  may  be  the  result  of  reme- 
dies (antitoxin)  administered  or  of  some  infection  originating  in  the 
gut.  Among  these  eruptions  are  the  various  forms  of  erythema  and 
roseola.     Erythema  urticatum  is  often  seen. 


394  TRE    SPECIFIC    IXFECTIOUS    DISEASES. 

Diagnosis. — The  diagnosis  of  diphtheria  must  be  considered  in  its 
clinical  and  bacteriological  aspects.  Clinically  the  characteristic  and 
ever-present  lesion  is  the  membrane.  This  is  seen  on  the  tonsils, 
uvula,  pillars  of  the  fauces,  and  the  posterior  pharyngeal  wall.  Its 
color  varies.  In  consistency  it  may  vary  from  a  thin  pellicle  or 
cloudy  discoloration  to  a  thick  adherent,  pultaceous  or  stringy  mass. 
In  a  large  proportion  of  cases  the  presence  of  the  membrane  and 
other  characteristics  are  j)resumptive  evidence  of  diphtheria.  On 
the  other  hand,  there  are  certain  forms  (not  very  frequent)  of  pseudo- 
membranous inflammation  of  the  tonsils  and  fauces  which  are  not 
truly  diphtheritic;  these  are  called  pseudodiphtheria  or  diphtheroid. 
In  these  cases  the  Klebs-Loffler  bacillus  is  not  found,  but  strepto- 
cocci, staphylococci,  and  other  bacteria  are  present.  Some  forms  of 
diphtheria  show  at  first  only  fibrinous  specks  on  the  tonsils ;  in  others 
there  are  small  necrotic  ulcerations  on  the  tonsil,  and  in  still  others 
the  diphtheria  may  simulate  an  acute  catarrhal  follicular  amygdalitis 
or  lacunar  amygdalitis.  These  cases  are  not  as  infrequent  as  was 
formerly  supposed.  In-  the  pseudomembranous  and  other  forms  of 
inflammation  of  the  throat  above  described  a  bacteriological  test 
should  always  be  made.  It  should  be  practised  as  a  routine  pro- 
cedure in  all  cases  of  angina.  Cultures  should  be  made  in  cases 
of  laryngeal  inflammation  in  which  no  membrane  is  visible  in  the 
fauces.  If  membrane  be  present  in  the  fauces,  and  a  culture  fail  to 
reveal  the  Klebs-Loffler  bacillus,  a  second  and  even  a  third  culture 
should  be  made.  I  have  frequently  established  the  presence  of  the 
specific  bacillus  in  membrane  in  cases  in  which  the  first  culture-test 
proved  negative.  It  is  not  a  reliable  nor  satisfactory  method  to 
spread  membrane  or  secretion  from  the  throat  direct  on  a  cover-glass, 
and  decide  from  such  a  preparation  the  nature  of  the  process. 

The  technique  of  culture-tests  is  scarcely  within  the  scope  of  this 
work.  It  is  sufficient  to  state  that  growth  can  be  obtained  within 
four  or  five  hours  if  the  culture-tube  is  subjected  to  a  temperature  of 
100.4°  to  102.2^  F.  (38°  to  39°  C.)  in  a  small  incubator.  Other 
diseases,  such  as  membranous  forms  of  stomatitis,  may  simulate  diph- 
theria. In  these  cases  the  culture  test  is  the  only  positive  mode  of 
making  a  diagnosis.  Certain  forms  of  laryngismus  stridulus  resem- 
ble acute  diphtheritic  laryngitis,  or  a  diphtheritic  process  may  be 
present  in  the  larynx  in  a  rachitic  infant  subject  to  attacks  of  laryn- 
gismus.    Cultures  should  be  made  in  all  such  cases. 

In  small  towns  and  country  districts  the  practitioner  without  the 
aid  afforded  by  laboratories  will  often  be  thrown  on  his  own  resources 
in  making  a  diagnosis.  In  such  cases  the  following  clinical  symptoms 
may  be  considered  fairly  presumptive  evidence  of  diphtheria: 

The  presence  of  membrane  on  a  tonsil  and  a  small  patch,  streak, 


DIPHTHERIA.  395 

or  speck  of  membrane  on  the  adjacent  surface  of  the  uvula  or  tip  of 
the  uvula ;  a  patch  of  membrane  on  the  tonsil  and  an  accompanying 
patch  on  the  posterior  pharyngeal  wall;  the  presence  of  a  croupy 
cough  and  stridulous  breathing  with  small  patches  of  membrane  on 
the  tonsil  or  epiglottis,  are  all  of  much  diagnostic  value.  The 
presence  of  albumin  in  the  urine  is  of  little  value  in  making  a  diag- 
nosis, as  it  may  be  present  in  non-diphtheritic  affections  and  absent 
in  diphtheria.  Constitutional  symptoms  are  only  of  corroborative 
value. 

It  is  well  known  that  the  most  virulent  forms  of  diphtheria  may 
at  first  be  manifested  by  few  constitutional  symptoms.  The  tempera- 
ture-curve is  not  characteristic.  If  a  patient  who  at  first  suffers  from 
a  catarrhal  tonsillitis  or  pharyngitis,  shows  within  twenty-four  hours 
minute  patches  of  membrane  either  on  the  uvula  or  pharynx,  it  may 
reasonably  be  assumed  that  true  diphtheria  is  present.  An  acute 
laryngeal  inflammation,  croupy  cough,  and  stridulous  breathing 
which  not  only  persist  beyond  the  first  twenty-four  hours  or  first 
night,  but  also  become  aggravated,  justify  a  diagnosis  of  diphtheria 
of  the  larynx,  although  no  membrane  is  visible  in  the  throat.  Gen- 
eral symptoms  are  of  little  diagnostic  value.  Rhinitis  at  first  accom- 
panied by  a  serous  and  later  by  a  fetid  sanguinolent  discharge,  with 
glandular  swellings  in  the  neck,  is  diagnostic  of  diphtheria. 

Adenitis  is  frequently  absent  at  the  outset  of  tonsillar  diphtheria, 
even  when  patches  of  membrane  of  some  size  are  present.  On  the 
other  hand,  a  simple  catarrhal  tonsillitis  is  often  accompanied  by 
marked  adenitis. 

Paralysis  of  the  soft  palate,  appearing  in  the  course  of  a  severe 
or  mild  pseudomembranous  tonsillar,  pharyngeal,  or  laryngeal  inflam- 
mation, or  after  the  affection  has  run  its  course,  points  strongly  to 
true  diphtheria,  although  cases  of  paralysis  of  the  soft  palate  follow- 
ing diphtheroid  have  been  reported.  The  color  of  the  membrane,  its 
detachability,  and  the  fact  that  a  bleeding  surface  is  left  after  its 
removal,  cannot  be  relied  upon  as  aids  to  diagnosis,  in  view  of  the 
fact  that  interference  with  the  membrane  is  not  advisable. 

Aphthae  with  pseudomembrane  over  the  vault  of  the  hard  palate, 
spreading  to  the  gums  and  cheeks,  are  seen  in  newly  born  and  older 
infants.  These  forms  of  pseudomembranous  stomatitis  are  the  result 
of  traumatism  inflicted  by  the  infected  fingers  of  the  nurse  or  mother, 
and  are  limited  to  the  parts  on  which  they  are  first  seen.  Such  septic 
membranes  rarely  spread  unless  the  exciting  causes  are  perpetrated. 

Herpes  of  the  pillars  of  the  fauces,  so-called  herpes  of  the  tonsils, 
are  often  mistaken  for  diphtheritic  patches.  With  a  suitable  light 
such  an  error  should  seldom  be  made. 

Following  the  ingestion  of  caustic  alkali  or  the  traumatism  con- 


396  TRE    SPECIFIC    INFECTIOUS    DISEASES. 

sequent  on  washing  or  rubbing  the  mucous  membrane,  aphthous 
ulcerations,  which  closely  simulate  diphtheritic  membranous  patches, 
are  prone  to  appear  over  the  hamular  process  of  the  palate  bone.  The 
history  of  the  case,  the  absence  of  diphtheria  elsewhere,  and  the  result 
of  a  culture  test  will  exclude  diphtheria. 

The  patches  of  necrotic  tissue  seen  on  the  tonsils,  pillars  of  the 
fauces,  and  uvula  following  tonsillotomy  and  ablation  of  adenoids, 
and  sometimes  accompanied  with  paralysis,  may  mislead  the  observer 
and  cause  him  to  make  a  diagiiosis  of  true  diphtheria. 

The  membranous  patches  which  appear  on  the  tonsils  of  scarlet 
fever  patients  at  the  outset  of  the  disease  are  for  the  most  part  diph- 
theroid. Unless  the  patient  has  been  exposed  to  a  double  infection, 
which  is  infrequent  in  private  practice,  the  patches  of  membrane 
which  appear  later  in  the  disease  are  also  of  a  diphtheroid  nature. 
True  diphtheria  may  coexist  with  scarlet  fever  (Baginsky,  Escherich, 
Councilman),  but  does  so  in  only  a  small  number  of  cases. 

The  appearance  of  a  pseudomembranous  exudate  on  the  tonsils  of 
a  patient  attacked  with  measles  should  be  regarded  as  diphtheritic 
until  the  contrary  has  been  proved.  The  laryngitis  with  croupy 
cough  and  breathing  often  complicating  measles  is  not,  as  a  rule, 
diphtheritic. 

Prognosis. — The  prognosis  and  mortality  vary  with  the  age  of  the 
patient,  the  form  and  severity  of  the  infection,  and  the  extent  to 
which  organs  other  than  the  fauces  and  larynx  are  involved.  Young 
infants,  unless  they  come  under  observation  early,  give  a  high  mor- 
tality rate.  Septic  forms  of  diphtheria  are  more  fatal  than  those  in 
which  the  process  is  a  distinctly  local  affection.  The  mortality  also 
varies  with  the  nature  of  the  epidemic.  In  Baginsky's  statistics  of 
2Y11  cases,  the  mortality  from  the  sixth  to  the  twelfth  month  was  52 
per  cent. ;  from  the  second  to  the  third  year,  37  per  cent.,  decreasing 
to  8  per  cent,  in  the  tenth  year.  The  death-rate  is  high  in  infants 
and  children  of  delicate  constitution  and  in  those  suffering  from  any 
form  of  dyscrasia. 

Treatment. — The  treatment  of  diphtheria  may  be  prophylactic, 
constitutional,  and  local. 

Prophylaxis. — The  patient  should  be  isolated  as  soon  as  the  mem- 
branous deposit  is  detected.  Other  children  of  the  family  who  have 
been  in  contact  with  the  patient  should  at  once  be  given  immunizing 
doses  of  antitoxin,  and  the  furniture  of  the  sick-room,  such  as  hang- 
ings and  carpets,  should  bo  removed,  only  the  most  necessary  articles 
being  retained.  The  room  should  be  well  ventilated.  The  nurse 
should  not  come  in  contact  with  other  members  of  the  family.  All 
articles  of  clothing  worn  by  the  patient  should  be  dipped  in  an  anti- 
septic solution  (corrosive  sublimate,  1:2000)  before  removal  from 


DIPHTEEBIA.  397 

the  sick-room.  The  physician,  before  entering  the  sick-room,  should 
cover  his  head  with  a  cap  and  wear  a  long  coat  or  bath-robe,  which 
should  be  hung  outside  the  sick-room.  If  it  is  necessary  for  members 
of  the  family  to  enter  the  room,  they  should  observe  the  same  precau- 
tions, and  on  leaving  the  room  they  should  gargle  or  rinse  the  mouth 
with  some  mild  cleansing  solution,  preferably  of  boric  acid.  A  throat 
culture  should  at  once  be  made.  The  swab  should  be  rubbed  over 
the  tonsils  if  they  are  the  seat  of  exudate ;  if  the  case  is  laryngeal, 
the  swab  is  passed  over  the  epiglottis  and  posterior  pharyngeal  wall. 
Utensils  used  in  feeding  the  patient  should  not  be  used  by  others. 

The  patient  after  convalescence  should  not  mingle  with  other 
children  until  culture  has  proved  the  absence  of  the  Bacillus  diph- 
therise  from  the  throat. 

Constitutional  Treatment. — Constitutional  treatment  consists  first 
in  the  administration  of  diphtheria  antitoxin.  It  is  not  within  the 
scope  of  this  work  to  enter  into  the  details  of  the  theory  of  action  of 
this  agent,  which  is  the  outcome  of  the  modern  experimental  method 
of  the  investigation  of  disease.  Its  place  in  the  therapy  of  diphtheria 
is  now  assured.  The  mortality  of  diphtheria  has  been  greatly  reduced 
since  its  introduction.  Baginsky  gives  the  following  figures,  show- 
ing the  mortality  before  and  after  the  introduction  of  antitoxin : 

Age.  Before.  After. 


Two  years 60.2  per  cent. 

Two  to  four  years 51.2         " 

Eight  to  ten  years 28.8        " 


25.8  per  cent. 
17.1        " 
10  " 


Of  5794  cases  in  private  practice  collected  by  the  American 
Pediatric  Society,  the  total  mortality  was  only  12.3  per  cent.  In 
the  cases  injected  on  the  first  day  of  the  disease  the  mortality  was 
7.3  per  cent.  In  the  laryngeal  form  of  diphtheria  the  results  have 
been  especially  favorable.  In  1704  cases  operated  and  not  operated 
there  was  a  mortality  of  21  per  cent.,  of  the  intubated  cases,  23 
to  27  per  cent.,  as  against  60  to  70  per  cent,  before  the  introduction 
of  antitoxin. 

Dosage. — The  dosage  varies  with  the  age  of  the  patient,  the  sever- 
ity of  the  infection,  and  the  duration  of  the  case  before  the  beginning 
of  treatment.  Mild  forms  of  local  membranous  affections  of  the 
tonsils  and  pharynx  coming  under  observation  on  the  first  day  should 
receive  doses  of  antitoxin  as  follows:  Up  to  one  year,  1000  to  1500 
units;  one  to  two  years,  2000  to  2500  units;  two  to  five  years,  2500 
to  5000  units.  If  the  disease  has  markedly  progressed  twenty-four 
hours  after  the  first  injection,  the  initial  dose  should  be  repeated. 
The  severer  forms  of  localized  diphtheria  with  marked  constitutional 
symptoms  should  receive  initial  doses  half  as  large  again  or  twice  as 
large.     Laryngeal  forms  should  receive  proportionately  large  doses. 


398 


TRE    SPECIFIC    INFECTIOUS    DISEASES. 


Fully  twice  the  above  doses  are  given  at  the  outset  of  the  laryngeal 
symptoms.  The  American  Pediatric  Society  recommends  as  an 
initial  dose  1500  units  for  a  child  under  two  years,  and  2000  units 
for  one  above  that  age.  I  employ  300  units  for  immunizing  purposes 
in  very  young  infants,  and  500  units  in  older  children. 

The  immunizing  power  extends  over  a  period  of  three  weeks.  It 
is  best  to  give  an  initial  dose  of  sufficient  amount,  so  that  a  repeti- 
tion of  the  dose  will  not  be  necessary ;  on  the  other  hand,  it  is  advis- 
able not  to  give  an  excessively  large  dose.  The  concentrated  anti- 
toxins are  preferable  both  on  account  of  the  diminished  bulk  and  the 
infrequency  with  which  skin-  and  joint-affections  follow  their  injec- 
tion. Recently  prepared  antitoxin  should  be  obtained,  for  it  has  been 
shown  that  this  agent  deteriorates  with  age  (Abbott),  and  then  no 
longer  contains  the  original  unit  values. 

EiG.  62. 


f?£-a  £:hmold,  n.  v. 


Antitoxin  syringe  with  asbestos  packing ;  can  be  taken  apart  and  sterilized. 


Time  of  Injection. — The  antitoxin  should  be  given  as  early  in 
the  course  of  the  disease  as  possible.  If  membrane  is  present,  no 
time  should  be  lost  in  waiting  for  the  result  of  the  culture  test,  for  if 
the  disease  is  not  true  bacillary  diphtheria  no  harm  can  result  from 
the  injection,  while  to  wait  may  be  hazardous  to  the  patient. 

Mode  of  Injection. — The  syringe  with  asbestos  packing  should 
be  used  for  making  injections.  Such  an  instrument  is  easily  cleansed 
and  boiled.  I  find  the  back  just  above  the  buttock  the  most  con- 
venient location  in  which  to  inject.  The  child  can  be  easily  held  if 
this  site  is  chosen.  The  parts  should  be  carefully  cleansed.  The 
injection  is  given  in  the  same  manner  as  a  hypodermic  injection. 
The  parts  should  not  be  rubbed  after  the  injection. 

Effect  of  Injection. — There  is  a  slight  temporary  rise  of  tempera- 
ture following  the  injection.  It  is  thought  to  be  due  to  the  entrance 
into  the  blood  of  the  additional  toxin  contained  in  the  antitoxin. 


DIPHTEEBIA.  399 

This  rise  is  succeeded  by  a  gradual  or  critical  fall,  which  continues 
until  the  temperature  is  subnormal.  The  membrane  ceases  to  spread 
and  exfoliates.  In  some  cases  these  phenomena  may  be  delayed 
twenty-four  hours.  The  next  day  the  pulse  drops,  the  prostration 
gives  way  to  a  clear  sensorium  and  good  heart  action,  and  sometimes 
the  children  sit  up  in  bed  and  play  with  toys.  The  glandular  swell- 
ing also  diminishes  markedly.  In  laryngeal  cases  if  there  has  been 
threatened  stenosis,  the  symptoms  retrograde.  Fully  one  half  retro- 
grade spontaneously.  On  the  other  hand,  if  the  temperature  persists 
high  after  twenty-four  hours  and  the  membrane  continues  to  spread, 
the  injection  should  be  repeated,  especially  if  the  swelling  of  the 
lymph-nodes  is  marked  and  there  are  symptoms  of  septic  infection. 

The  effect  of  an  injection  of  antitoxin  on  the  blood  is  to  diminish 
the  number  of  leucocytes ;  just  prior  to  the  fall  of  temperature  there 
is  a  critical  hyperleucocytosis  (Ewing,  Schlessinger).  Albuminuria 
continues,  but  this  is  also  the  case  not  only  when  no  antitoxin  has 
been  used,  but  also  in  almost  any  infectious  disease  in  which  bacteria 
or  their  toxins  circulate  in  the  blood. 

The  eruptions  which  occur  after  the  injection  of  antitoxin  are  of 
interest.  At  the  site  of  the  injection  an  abscess  or  phlegmon  may 
form.  This  is  the  result  of  uncleanliness  in  technique  or  is  due  to 
some  irritating  substance  in  the  antitoxin.  A  brawny  erythema 
which  gradually  disappears  may  appear  in  a  day  or  more  at  the  site 
of  injection.  The  injection  may  be  rapidly  followed  by  a  painful 
eruption  on  the  extremities,  consisting  of  circumscribed  violet  colored 
spots,  closely  resembling  erythema  nodosum.  The  subcutaneous  tis- 
sues are  swollen,  the  joints  are  painful,  and  in  addition  there  may  be 
elevated  temperature  and  a  cardiac  murmur.  Herpes  labialis  and 
herpes  nasalis,  urticaria-like  general  eruptions,  and  morbilliform  or 
scarlatiniform  eruptions  have  followed  injections.  These  eruptions 
appear  from  a  few  days  to  fourteen  days  after  the  injection. 

Conjunctival  injection,  tachycardia,  and  arrhythmia  may  be 
present. 

The  acute  symptoms  described  above  subside  in  most  cases  within 
two  or  three  days. 

Kidney  irritation  may  follow  the  injection  of  large  doses  of  anti- 
toxin. In  many  of  the  cases  reported,  however,  the  renal  symptoms 
have  not  been  due  to  the  antitoxin  alone,  and  the  same  may  be  said 
of  the  recorded  cases  of  endocarditis  following  antitoxin  injections. 

The  introduction  of  antitoxin  has  by  no  means  lessened  the  neces- 
sity of  careful  general  management  of  a  case  by  the  physician.  The 
temperature  is  controlled  or  modified  by  hydrotherapeutic  procedures. 
Antipyretics  of  the  coal-tar  series  should  not  be  administered,  as  they 
weaken  the  heart. 


400 


TSE    SPECIFIC   INFECTIOUS    DISEASES. 


If  signs  of  cardiac  paralysis  of  the  early  type  set  in,  full  doses  of 
the  cardiac  remedies^ — digitalis  (if  the  pulse  is  rapid),  strychnine, 
caffein,  camphor,  and  whiskey — are  given.  Of  the  remedies,  digi- 
talis must  be  used  cautiously,  else  the  pulse  will  be  seriously  depressed. 
Strychnia  and  caffein  are  the  best  and  most  available  remedies.  In 
the  cases  of  cardiac  irregularity  it  is  best  not  to  multiply  drug  reme- 
dies, or  the  stomach  will  be  upset  and  the  general  conditions  be  aggra- 
vated. To  a  child  three  years  of  age  we  may  give  Kso  grain  of 
strychnia  every  three  hours ;  whereas  caffein  is  best  used  in  the  form 


Fig.  63. 

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Septic  form  of  tonsillar  diphtheria ;  both  tonsils  and  soft  palate  involved  with  naso- 
pharynx. Persistence  of  temperature  and  recurrence  of  membrane  after  antitoxin  injec- 
tions on  the  sixth  day.  Injection  of  additional  antitoxin  and  critical  drop  of  temperature 
thereafter.     Recovery.     Boy,  six  years  of  age. 


of  the  citrate,  a  grain  to  a  child  of  three  years  of  age  at  similar  inter- 
vals. The  child  is  kept  recumbent  and  the  most  assimilable  forms 
of  food  are  given,  such  as  milk,  kumyss,  soft  eggs,  raw  or  boiled.  In 
those  cases  in  which  there  is  gallop  rhythm  or  extreme  restlessness, 
digitalis  in  combination  with  morphin  is  given.  To  a  child  three 
to  five  years  of  age,  2  minims  of  the  tincture  of  digitalis  may  be  given 
every  three  hours,  and  1  or  2  minims  of  Magen die's  solution  by  the 
mouth.  The  latter  is  repeated  only  when  needed.  In  order  to  guard 
against  cardiac  weakness  in  the  later  period  of  the  disease,  a  cardiac 
stimulant,  such  as  strychnine,  is  given  in  small  doses  throughout  the 
illness  and  in  convalescence.  The  patient  is  not  allowed  to  sit  up 
too  early  should  signs  of  cardiac  irregularity  appear  at  the  outset  of 


DIPHTHEEIA.  401 

convalescence.  In  all  cases  of  diphtheria  the  utmost  caution  should 
be  exercised  in  reference  to  the  heart. 

The  infant  should  not  be  nursed  at  the  breast,  lest  the  breast  be 
infected.  The  milk  should  be  pumped  off  and  fed  to  the  infant  with 
a  bottle.  If  there  is  diarrhoea,  the  milk  is  suspended  and  the  bowel 
irrigated.  The  milk  should  not  be  resumed  until  all  danger  from 
this  source  is  past.  Alcohol  is  given  in  moderate  doses  if  the  pros- 
tration, pulse,  and  temperature  warrant  it.  Infants  under  a  year 
receive  half  a  drachm  (2.0)  of  whiskey  every  three  hours;  infants 
more  than  two  years  of  age,  a  drachm  (4.0)  at  the  same  intervals. 
Diphtheria  patients,  especially  those  suffering  from  the  septic  form 
with  constitutional  symptoms,  are  kept  recumbent.  The  adminis- 
tration of  remedies  is  not  forced,  for  struggling  on  the  part  of  the 
patient  may  prove  dangerous  to  the  heart.  During  convalescence  the 
whiskey  may  be  replaced  by  wine.  In  these  cases  strychnine  in  small 
doses  (grain  ^oo  [0.0003] )  should  be  continued  for  some  time.  I 
advise  a  return  to  a  mixed  nutritious  diet  in  all  cases  as  soon  as  the 
temperature  is  normal ;  in  this  way  the  effect  of  the  toxins  on  the 
tissues  is  counteracted  as  much  as  possible. 

Some  physicians  still  resort  to  the  internal  administration  of  cor- 
rosive sublimate  in  doses  of  grain  Koo  (0.0006)  or  more,  according 
to  the  age  of  the  patient.  It  is  given  in  the  septic  tonsillar  and  nasal 
cases,  and  also  in  the  laryngeal  forms  of  diphtheria. 

Local  Treatment.^ — The  presence  of  bacteria  other  than  the  diph- 
theria bacillus  around  the  local  lesions  necessitates  the  use  of  local 
cleansing  and  disinfecting  measures.  In  very  young  infants  the 
nasal  discharges  are  washed  away  by  means  of  a  glass  syringe  with 
a  blunt  rubber  tip.  The  infant  is  laid  on  the  side,  and  the  nurse, 
standing  behind  the  patient,  irrigates  the  nostrils  with  normal  salt 
solution  at  110°  F.  (43.3°  C),  as  shown  in  Fig.  9.  A  pus  basin 
is  held  underneath  the  chin.  Older  children  will  struggle,  but  by 
suasion  they  may  be  irrigated  in  the  sitting  posture.  If  there  is 
much  resistance,  it  is  not  desirable  to  insist  on  irrigation.  In  irri- 
gating, the  syringe  should  have  a  position  parallel  with  the  floor  of 
the  nasal  fossse.  Spraying  with  a  mild  solution  of  Listerine  or 
Dobell's  solution  is  possible  in  some  children,  impracticable  in  others. 
The  lymph-nodes,  if  slightly  enlarged,  are  best  treated  by  the  appli- 
cation of  warm  oil  of  hyoscyamus ;  if  very  much  swollen,  the  appli- 
cation of  cloths  wrung  out  in  ice-cold  water  is  of  great  utility.  Small 
pieces  of  ice  swallowed  whole  are  grateful  to  the  patient. 

Treatment  of  Laryngeal  Diphtheria. — In  cases  of  mild  laryngeal 
diphtheria  an  injection  of  antitoxin  should  be  given.  The  patient 
should  be  placed  under  a  tent,  and  gi-ains  x  (0.6)  of  calomel  sublimed 
every  two  or  three  hours,  according  to  the  necessities  of  the  case. 

26 


402  THE    SPECIFIC    INFECTIOUS    DISEASES. 

The  efficacy  of  the  calomel  vapor  is  increased  by  passing  steam  into 
the  tent  at  the  same  time.  A  convenient  method  is  to  place  the 
calomel  in  a  spoon,  and  heat  the  spoon  over  an  ordinary  candle,  held 
within  the  tent.  The  swelling  of  the  larynx  cansed  by  the  invasion 
of  the  Bacillus  diphtherise  and  other  bacteria  is  quickly  relieved  by 
the  calomel,  particularly  in  croupy  cases  with  little  or  no  membrane 
visible  above  the  larynx.  A  tent  may  be  improvised  and  steam  satu- 
rated with  benzoin  or  thymol  may  also  be  passed  into  the  tent.  A 
croup  kettle  may  be  improvised  from  an  ordinary  teapot  or  one  sold 
for  the  purpose  may  be  employed.  It  is  sometimes  necessary  to  sus- 
pend the  steam  inhalations  for  an  hour  or  longer,  for  the  purposes  of 
ventilation.  The  general  treatment  as  to  the  heart,  temperature,  and 
food  is  the  same  as  in  the  tonsillar  forms  of  diphtheria.  If  signs  of 
mechanical  obstruction  appear,  intubation  is  indicated. 

Intubation.- — To  Joseph  O'Dwyer,  of  'New  York,  belongs  the 
credit  of  having  perfected  intubation  as  a  method  of  relieving  mem- 
branous obstruction  of  the  larynx  in  diphtheria.  Intubation  in 
America  and  on  the  continent  of  Europe  has  completely  displaced 
tracheotomy  as  a  remedy  for  relieving  laryngeal  obstruction  due  to 
diphtheria. 

Instruments. — Intubation  tubes  (Fig.  64)  are  of  metal  coated 
with  rubber,  though  originally  made  of  gilt  metal.     The  tubes  are 

Fig.  64.  Fig.  65. 


O'Dwyer  tube.  Gauge  for  the  age  of  the 

patient. 

graduated  (Fig.  65)  according  to  the  age  of  the  patient,  and  in  their 
present  form  are  the  most  ingeniously  devised  instruments  ever  giyen 
by  American  medicine  to  the  world.  The  tubes  are  furnished  with 
obturators,  which  fit  into  a  handle,  the  introducer  (Fig.  66).  There 
is,  in  addition,  a  forceps  (Fig.  67)  with  small  departing  blades,  called 
the  extractor.  Finally  there  is  a  gag  (Fig.  68)  so  constructed  that 
it  may  be  introduced  into  the  mouth  and  kept  in  position  without 
obstructing  the  view  of  the  operator. 

Indications. — We  intubate  when  a  progressive  dyspnoea,  which 
produces  sensible  exhaustion,  exists.  O'Dwyer  never  tubed  the 
larynx  except  as  a  dernier  ressort,  and  did  not  approve  of  early 
tubage.  If  an  infant  or  child  shows  marked  retraction  of  the  supra- 
sternal notch,  retraction  of  the  epigastrium,  and  stridor,  with  accom- 
panying labored  breathing,  we  should  at  once  proceed  to  tube  the 
larynx. 

Mode  of  Operating. — The  patient  is  wrapped  in  a  blanket  and 


DIPIITIIEIUA. 
Fig.  66. 


403 


O'Dwyer  tube,  obturator  and  handle. 


Fig.  67. 


The  O'Dwyer  extractor. 


Fig.  68. 


Gag  of  the  O'Dwyer  set. 


404 


TEE    SPECIFIC    INFECTIOUS    DISEASES. 
Fifi.  69. 


Introduction  of  the  tube  along  the  index  finger. 


Fig.  70. 


I'assing  the  tube  over  the  epiglottis. 

Figs.   60,  70.^ — The  op€ration  of  intubation  of  the  larynx.     I'osition  of  child,   operator 

and,  assistant. 


DIPHTHEEIA. 


405 


Fig.  71. 


>w  N-'- 


Z?/.-i^' 


Introduction  of  the  tube  into  the  chinlj  of  the  glottis. 


Fig.  72. 


The  index  finger  pushes  the  liead  of  the  tube  into  place  in  the  Uu'yux. 


Figs.   71,   72. — The  operation  of  intubation  of  the  larjmx.     Position  of  child,   operator 

and  assistant. 


406 


THE    SPECIFIC    INFECTIOUS    DISEASES. 


held  upright  in  the  arms  of  a  nurse,  so  that  the  head  of  the  patient 
is  on  a  level  convenient  to  the  operator,  v^ho  stands  facing  the  patient. 
An  assistant  standing  behind  the  nurse  steadies  the  head  of  the  patient. 
The  gag  is  introduced  by  depressing  the  tongue  and  jav^v^ith  a  tongue- 
depressor.  The  assistant  steadies  the  gag  as  he  holds  the  head  tilted 
very  slightly  backward.  The  tube,  threaded  with  a  silk  ligature,  is 
with  its  introducer  held  firmly  with  the  right  hand.  The  index  finger 
of  the  left  hand  is  now  introduced  into  the  mouth  to  the  root  of  the 
tongue  and  search  made  for  the  epiglottis.     In  young  infants^  the 

Fig.  73. 


Method  of  hooking  forward  the  epiglottis  in  intubation. 

epiglottis  is  short.  The  finger  must  be  introduced  quite  deeply,  feel- 
ing the  arytenoid  cartilages  of  the  larynx,  and  is  then  drawn  upward 
until  the  epiglottis  is  hooked  forward.  The  index  finger  now  holds 
the  epiglottis  (Fig.  73),  and  in  a  small  larynx  a  skilled  operator  can 
also  feel  the  arytenoids  (Fig.  74).  The  tube  is  now  introduced  in 
the  median  line  of  the  mouth  along  the  palmar  surface  of  the  index 
finger  (Fig.  G9),  and  the  finger  guides  the  tube  over  the  epiglottis 

'  Peculiarities  of  the  Larynx. — Thomson  anrl  Turner  have  shown  that  the  infan- 
tile form  of  larynx  diiifers  materially  from  that  found  later  in  life.  At  birth  and 
in  infants  and  young  children  the  epiglottis  is  very  small  and  gutter-shaped.  The 
glottis  is  guarded  above  by  the  aryteno-epiglottie  folds,  which  are  closely  approxi- 
mated to  each  other.  Toward  the  tenth  year  the  epiglottis  becomes  much  flattened, 
the  aryteno-epiglottie  folds  become  widely  separated,  and  the  larynx  assumes  the 
adult  type.     It  is  important  to  remember  these  points  in  the  operation  of  intubation. 


DIPHTHEBIA. 


407 


and  into  the  chink  of  the  glottis  and  prevents  its  slipping  into  the 
oesophagus  (Fig.  70). 

■  The  instrument  should  always  be  kept  in  the  median  line.  The 
index  finger  holding  the  epiglottis  should  be  held  well  to  the  angle  of 
the  mouth,  so  as  to  obtain  plenty  of  room.  'No  force  should  be  used, 
else  false  passages  will  be  made.  If  the  first  attempt  at  introduction 
does  not  succeed,  we  should  not  persist  too  long,  but  remove  the  intro- 
ducer rapidly  and  give  the  larynx  a  few  moments  to  recover  its  action, 
and  then  try  again.  As  the  tube  passes  into  the  chink  of  the  glottis 
the  handle  of  the  introducer  is  elevated,  as  in  Fig.  71,  causing  the 
end  of  the  instrument  to  lie  against  the  base  of  the  tongue.  The  tube 
is  released,  the  introducer  and  obturator  withdrawn,  and  the  index 
finger  gently  presses  the  head  (Fig.  72)  of  the  tube  into  the  larynx. 
The  gag  is  withdrawn,  and  the  silken  thread  passed  over  the  ear  of 

Fig.  74. 


^W'ry^' 


^- 


The  infantile  larynx.  Its  development  into  the  adult  type  at  the  age  of  nine  years. 
1.  Infant,  three  months  of  age.  2.  Child,  three  and  a  half  years  of  age.  3.  Boy,  nine 
years  of  age.  Enlargement  upward  of  the  epiglottis  and  shaping  of  the  arytenoid 
cartilages.      (Thomson  and  Turner,  British  Medical  Journal,  December  1,  1900.) 


the  patient  and  fixed  back  of  the  ear  with  a  piece  of  rubber  plaster. 
Some  operators  remove  the  thread  after  ten  minutes.  The  advan- 
tages of  leaving  the  thread  are  that,  should  the  tube  be  coughed  up 
in  the  absence  of  the  physician,  it  can  be  recovered  by  the  nurse.  In 
extubating,  it  is  an  aid  in  removing  the  tube. 

JSTo  ansesthetic  is  required,  and  ordinary  assistance  only  is  neces- 
sary. The  air  passing  into  the  bronchi  is  moistened  in  its  passage 
through  the  natural  passages.  The  danger  that  food  particles  may 
pass  into  the  larynx  has  been  exaggerated.  The  detachment  of  mem- 
brane in  front  of  the  tube  is  very  infrequent.  Should  it  happen,  and 
the  membrane  not  be  expelled  on  removal  of  the  tube,  tracheotomy  is 
admissible  if  asphyxia  is  imminent.  It  sometimes  happens  that  the 
tube  is  expelled  many  times  after  introduction.  It  should  be  reintro- 
duced or  a  larger  tube  employed. 


408  TEE    SPECIFIC    INFECTIOUS    DISEASES. 

If  the  operator  has  chosen  to  leave  the  silken  cord  of  the  tube  in  situ,  it 
should  be  passed  through  the  space  between  the  first  molar  and  bicuspid  tooth, 
to  avoid  its  being  gradually  bitten  through.  Should  it  be  bitten  through,  the 
finger  is  introduced  into  the  mouth  to  the  top  of  the  tube  and  the  thread  with- 
drawn, while  the  tube  is  kept  in  the  larynx  with  the  finger. 

The  tube  is  allowed  to  remain  from  twenty-four  hours  to  five 
days.  Since  the  introduction  of  antitoxin  the  tube  is  taken  out 
much  sooner  than  was  formerly  the  practice.  If  there  is  marked 
improvement  in  two  or  three  days,  removal  of  the  tube  should  be 
attempted  and  the  effect  of  such  a  procedure  on  the  breathing  should 
be  observed. 

Both  in  the  'New  York  and  Boston  hospitals  many  operators  prefer 
the  recumbent  to  the  upright  position  in  introducing  the  tube.  The 
patient  is  easily  intubed  in  bed  or  on  the  table  in  the  prone  position. 

Extubation. — The  patient  is  placed  in  the  same  position  as  for 
intubation.  The  left  index  finger  is  passed  into  the  mouth  and  search 
made  for  the  epiglottis,  the  tip  of  the  finger  resting  on  the  arytenoids. 
The  extractor  is  passed  along  the  palmar  side  of  the  finger  and  is 
guided  into  the  opening  in  the  tube  by  the  tip  of  the  finger.  Extuba- 
tion is  more  difficult  than  intubation.  The  extractor  should  be  regu- 
lated by  means  of  a  small  screw,  so  that  the  blades  do  not  open  too 
far.  This  is  to  guard  against  injury  to  the  soft  parts  of  the  larjaix 
should  the  opening  of  the  tube  not  be  entered. 

Dangers. — The  dangers  of  intubation  include  detachment  of  mem- 
brane during  introduction,  laceration  of  the  parts,  the  formation  of 
false  passages,  and  asphyxia.  The  first  rarely  occurs  unless  force 
is  used.  The  second  can  only  occur  as  a  result  of  rough  and  unskilled 
efforts  at  intubation.  The  third  occurs  only  following  prolonged 
efforts  at  introduction  of  the  tube.  Even  a  skilful  operator  may  pass 
the  tube  into  the  ventricle  of  the  larynx.  jSTorthru^D  has  published  a 
case  in  which  there  was  a  false  pocket  above  the  cords  which  prevented 
the  entrance  of  the  tube  into  the  larynx.  In  other  cases  there  is  what 
is  described  by  O'Dwyer  as  subglottic  stenosis.  ISTorthrup  thinks 
that  this  is  due  to  swelling  of  the  mucous  membrane  at  the  level  of 
the  cricoid  cartilage.  In  these  cases  introduction  of  the  tube  is  very 
difficult.  The  operator  may  be  compelled  to  use  force  to  push  the 
tube  past  the  stenosis  or  a  smaller  tube  may  be  employed.  While 
the  tube  is  being  worn,  it  may  become  obstructed  by  membrane.  This 
is  indicated  by  a  return  of  the  croupy  cough,  a  snarling,  flapping 
sound,  and  obstruction  to  ex]nration. 

To  obviate  these  difficulties,  O'Dwyer  has  had  short  tubes  con- 
structed without  a  retaining  flange.  These  tubes  have  a.  special  intro- 
ducer. The  largest  size  for  the  age  is  chosen,  and  the  tube  forced 
into  the  larynx.     These  tubes  should  be  used  oidy  by  skilled  opera- 


DIPETHEEIA. 


409 


Fig.  75. 


tors.  The  tubes  are  allowed  to  remain  but  a  short  time  in  the  larynx. 
Other  complications  are  the  formation  of  granulations  or  ulcerations 
around  the  lower  end  of  the  tube  if  it  is  too  long,  and  at  the  cricoid 
cartilage  if  it  is  too  large.  The  former  condition  is  not  serious ;  the 
latter  may  destroy  the  cartilage.  Granulations  may  form  about  the 
head  of  the  tube.  In  this  case  tubes  with  built-up  heads  are  used  to 
press  on  the  granulations,  thus  causing  them  to  atrophy  (Fig.  75). 

Feeding. — Feeding  the  patient  after  intro- 
duction of  the  tube  requires  care.  Most  infants 
will  nurse  with  the  tube  in  the  larynx.  In  some 
there  is  considerable  difficulty  in  swallowing. 
The  patient  is  taken  in  the  lap  of  the  nurse  and 
fed  with  the  head  held  a  little  lower  than  the 
body.  Fluids  thus  cannot  enter  the  trachea  and 
cause  pneumonia. 

Treatment  of  the  Complications Bronchopneu- 

moiiia. — The  treatment  of  the  bronchopneumonia 
which  complicates  diphtheria  is  similar  to  that 
employed  in  the  treatment  of  a  primary  affection. 
The  question  of  the  further  administration  of 
antitoxin  always  rises  in  these  cases.  I  give  it 
in  full  doses,  since  it  is  known  that  the  Bacillus 
diphtherige  is  the  causative  factor. 

Gastro-enteritis. — The  gastro-enteritis  which 
complicates  diphtheria  it  apt  to  prove  very  serious 
the  same  treatment  as  a  primary  gastro-enteritis. 

DipJitJieria  of  the  Vulva. — Both  the  severe  and  the  mild  cases  of 
diphtheria  of  the  vulva  or  of  the  vulva  and  vagina  should  be  treated 
with  antitoxin.  In  some  of  the  mild  forms  of  undoubted  bacillary 
origin  which  I  have  seen,  the  membrane  was  easily  removable.  In 
these  cases,  contrary  to  the  practice  in  the  tonsillar  cases,  I  remove 
the  membrane  with  a  spud  wrapped  with  cotton.  The  bleeding  sur- 
face left  after  removal  is  painted  with  a  10  per  cent,  solution  of  silver 
nitrate  once  daily.  I  have  cured  cases  by  this  method  alone.  If 
there  are  extensive  swelling,  necrosis,  and  gangrene,  this  method  will 
be  of  no  avail,  and  antitoxin  should  be  given  in  full  doses,  and  re- 
peated according  to  indications. 

Paralyses. — The  treatment  of  diphtheritic  and  especially  post- 
diphtheritic paralyses  is  at  present  largely  empirical.  The  symptoms 
appear  with  the  degenerations  in  full  progress.  Of  all  the  remedies 
recommended.  Fowler's  solution  in  tonic  doses  has  seemed  to  give 
the  best  results.  I  have  seen  patients  recover  when  given  arsenic, 
nutritious  food,  and  abundant  fresh  air.  Hypodermic  injections 
of  strychnine  are  of  questionable  value.     Electricity  is  of  value  as 


Built-up  tubes. 


It  should  receive 


410  THE    SPECIFIC    INFECTIOUS    DISEASES. 

an  adjuvant  to  massage  of  the  muscles  only  in  general  paralysis.  It 
is  questionable  whether  in  some  cases  it  is  not  capable  of  doing  great 
harm  by  tiring  nerve  and  muscle.  I  find  that  patients  do  very  well 
with  hydrotherapy  and  massage.  In  these  cases  the  last  reaction  to 
reappear  is  the  patellar  reflex. 

Diphtheroid  (Pseudodiphtheria;  False  Diphtheria). — The  term 
diphtheroid  includes  all  pseudomembranous  formations  not  caused  by 
the  Klebs-Loffler  bacillus.  It  was  first  proposed  in  1860  by  Boussage, 
and  has  recently  been  adopted  by  Weigert,  Escherich,  Heubner,  and 
Behring. 

Occurrence. — This  form  of  pseudomembranous  formation  is  most 
frequently  met  with  in  the  exanthemata,  especially  scarlet  fever  and 
measles.  In  the  former  it  is  a  common  complication.  It  is  also 
met  in  other  conditions,  and  fevers  such  as  typhoid,  and  may  occur  as 
a  primary  affection. 

Etiology. — The  cases  met  in  the  exanthemata  were  first  described 
by  Prudden,  who  believed  that  the  process  was  due  to  a  streptococcus, 
the  Streptococcus  diphtherise.  Since  then,  the  occurrence  of  the 
streptococci  has  been  confirmed,  but  there  have  also  been  added  to 
this  group  of  pseudomembranous  inflammations  cases  in  which  the 
pseudomembrane  is  caused  by  a  diplococcus,  the  so-called  Roux  coccus. 
The  pneumococcus  (Jaccoud  and  Menetrier)  may  also  cause  a  pseu- 
domembranous angina.  The  Bacterium  coli  and  the  gonococcus  (the 
latter  in  newly  born  infants)  may  cause  a  membranous  formation  in 
the  mouth  and  throat.  The  Staphylococcus  pyogenes  aureus  is  also 
found  in  these  diphtheroid  membranes. 

By  far  the  most  important  group  is  that  first  mentioned,  the  pseu- 
domembranous or  diphtheroid  inflammation  caused  by  the  Strepto- 
coccus pyogenes,  which  is  none  other  than  that  isolated  by  Prudden. 
These  cases  are  characterized  by  their  favorable  course;  while  the 
mortality  in  diphtheria  varies  from  20  to  35  per  cent.,  according  to 
the  age  of  the  patient,  the  virulence  of  the  epidemic,  and  the  early 
administration  of  antitoxin,  the  mortality  of  the  diphtheroid  cases 
ranges  from  3  to  5  per  cent.  (Park,  Baginsky). 

Symptoms  and  Course. — The  pseudomembrane  occurs  on  the  ton- 
sils, pharynx,  and  larynx.  There  are  adenopathy  and  fever.  The 
prostration  and  constitutional  disturbance  are  much  less  than  in  true 
diphtheria.  Membranes  and  casts  of  the  larynx  and  trachea  may  be 
expelled.  Suppuration  of  the  lymph-nodes  may  also  occur.  In  many 
of  these  cases  there  is  a  complicating  bronchopneumonia  of  the  strep- 
tococcus type  (Prudden  and  !N"orthrup),  which  usually  results  fatally. 

Diagnosis. — It  is  not  possible  to  make  a  diagnosis  of  diphtheroid 
from  the  gross  appearance  of  the  membrane.  The  culture-test  is  the 
only  reliable  method  of  determining  the  nature  of  a  pseudomembra- 


SCBOFULA    OB    SCBOFULOSIS.  411 

nous  exudate.     If  the  first  culture  gives  a  negative  result,  a  second 
one  should  be  made. 

Treatment. — Clinically  the  treatment  is  much  the  same  as  in  true 
diphtheria.  The  administration  of  antitoxin  should  not  he  delayed 
until  the  nature  of  the  exudate  is  determined.  It  is  then  discon- 
tinued. An  exception  to  this  rule  may  be  made  in  the  scarlatinal 
form  of  diphtheroid,  in  which  it  is  safe  to  wait  for  the  result  of  the 
culture-test,  unless  it  is  known  that  the  patient  has  been  exposed  to 
diphtheritic  infection.  In  such  a  case  antitoxin  should  be  adminis- 
tered. In  laryngeal  obstruction  the  indications  for  treatment  are  the 
same  as  in  true  diphtheria. 

SCROFULA    OR    SCROFULOSIS. 

The  tendency  in  some  quarters  is  to  ignore  the  existence  of  scrofu- 
losis  as  a  clinical  entity  and  to  rank  all  these  and  allied  conditions 
under  the  rubric  of  general  tuberculosis,  Bayle  and  Laennec  first 
described  this  condition. 

Definition. — Scrofula  is  a  form  of  infantile  tuberculosis  engrafted 
on  a  lymphatic  constitution,  manifesting  itself  in  superficial  catarrh 
and  infections  of  the  skin,  enlargement  of  the  lymph-nodes,  and 
inflammations  of  the  joints  and  bones. 

Forms.- — There  the  two  forms  of  scrofulosis : 

a.  The  tuberculous  form,  which  is  practically  identical  with 
cutaneous,  lymphatic,  and  bone  tuberculosis. 

h.  The  mixed  form,  in  which  both  the  tubercle  bacillus  and  the 
pyogenic  bacteria  are  found  in  the  lesions  and  products  of  inflam- 
mation. 

The  second  form  may  not  show  the  effects  to  as  great  an  extent 
as  the  first  form  of  the  so-called  tuberculo-toxic  action  of  the  toxins 
of  the  tubercle  bacillus  on  the  skin,  mucous  membranes  and  lymph- 
nodes. 

Occurrence. — Scrofulosis  is  almost  exclusively  a  disease  of  child- 
hood and  youth,  and  is  rarely  seen  after  the  twentieth  year.  Henoch 
and  Birch-Hirschfeld  state  that  the  majority  of  cases  occur  between 
the  third  and  the  fifteenth  year.  Females  are  more  frequently 
affected  than  males.  Ruhl  found  it  to  be  most  common  between  the 
sixth  and  the  tenth  year. 

Etiology. — In  considering  the  etiology  of  scrofulosis,  it  should  be 
borne  in  mind  that  at  the  period  of  life  during  which  the  disease 
occurs  the  lymph-nodes  are  not  structurally  fully  developed.  On 
account  of  this  condition  and  of  deficiencies  of  other  tissues  such  as 
the  skin  and  mucous  membranes,  bacteria  obtain  easy  access  through 
the  skin,  mucous  membranes,  and  lymph-vessels  even  when  there  is 
no  breach  of  continuity  of  surface  (Cornet). 


412  TSE    SPECIFIC    IXFECTIOrS    DISEASES. 

It  is  also  true  that  certain  individuals,  especially  those  of  a 
lymphatic  tendency  once  infected,  show  a  predisposition  to  affections 
of  the  mucous  membranes  and  other  tissues. 

The  essential  causes  of  scrof  ulosis  are  the  tubercle  bacillus  and  the 
pyogenic  bacteria  just  mentioned.  These  bacteria  are  present  in 
ill-ventilated  rooms  occupied  by  phthisical  patients.  Scrofulous  in- 
fection may  be  traced  to  parents,  brothers,  sisters,  nurses,  and  play- 
mates. Dried  sputum  is  a  prolific  source  of  infection.  Infection  is 
favored  by  any  solution  of  continuity  of  the  skin  or  mucous  mem- 
branes, and  also  by  hyper^emia  or  oedema  of  these  tissues. 

The  predisposing  factors  are  social  conditions,  unhygienic  sur- 
roundings, moist  dark  dwellings,  uncleanliness,  improper  or  insuffi- 
cient food,  and  lack  of  fresh  air  and  exercise.  The  overcrowding  in 
the  poorer  quarters  of  cities  affords  abundant  opportunities  for  infec- 
tion. Any  weakening  of  the  system  by  infectious  diseases,  such  as 
measles,  pertussis,  scarlet  fever,  diphtheria,  rachitis,  struma,  cretin- 
ism, and  erysipelas,  may  be  the  starting-point  for  infection.  Trau- 
matism or  frostbite  favors  the  entrance  of  bacteria. 

Morbid  Anatomy. — The  mucous  membranes  are  the  seat  of  hyper- 
aemia  and  thickening.  There  are  increased  secretion  and  activity  of 
the  glands,  also  desquamation  of  epithelium,  and  excretion  of  serum 
and  blood-elements  from  the  surface  of  the  membrane.  Adenoids. 
enlarged  tonsils,  bronchitis,  intestinal  and  vaginal  catarrh,  are  the 
most  common  of  the  lesions  of  the  mucous  membrane. 

Skiyi. — There  are  eczema,  thickening  of  the  epidermis,  and  trans- 
udation of  serum  and  elements  of  the  blood  (erythrocytes  and  leuco- 
cytes).    Ecthymatous  eruptions  are  common.     There  may  be  lupus. 

Cornea. — The  cornea  shows  conjunctivitis  and  phlyctenulse. 

Lymph-nodes.  - —  The  lymph-nodes  show  hyperplasia,  which  is 
scarcely  noticeable  in  the  early  stages.  They  subsequently  enlarge 
to  form  tumor  masses,  which  may  soften  as  a  result  of  suppuration 
or  may  retrograde  to  the  normal. 

The  nodes  in  almost  any  part  of  the  body  may  be  involved.  They 
are  enlarged  to  a  greater  or  less  degree,  and  are  infiltrated  with 
tubercle.  On  section  they  show  either  simple  caseation  or  mixed 
infection.  The  latter  is  the  case  if  pyogenic  infection  is  combined 
with  the  tuberculous  form.  Xodes  which  are  the  seat  of  cheesy 
degeneration  may  soften  and  break  down,  forming  cold  abscesses. 
These  may  open  externally  oi  into  the  bronchi,  bloodvessels,  pericar- 
dium, or  peritoneum. 

Joints  and  Bones.— In  the  bones  the  tuberculous  invasion  gives 
rise  to  fungus  or  dry  caries.  Several  such  foci  may  be  present  in 
the  same  bone.  These  foci  may  heal  and  years  afterward  become 
inflamed  as  a  result  of  traumatism  or  infectious  disease. 


SCBOFVLA    OB    SCBOFULOSIS.  413 

The  fingers,  toes,  and  extremities  of  the  long  bones  are  thickened 
as  the  result  of  periosteal  inflammation.  The  ends  of  the  hones  are 
the  seat  of  tuberculous  osteomyelitis.  The  joints  may  be  involved. 
At  first  there  is  serous  exudate  without  perforation  into  the  joint 
of  the  tuberculous  foci.  Later  there  are  thickening  of  the  synovial 
membranes  and  seropurulent  exudate  into  the  joint-cavity,  with 
destruction  of  the  cartilages  and  heads  of  the  bones. 

Symptoms. — General  Clinical  Picture.- — The  patient  is  anaemic, 
but  not  necessarily  emaciated ;  on  the  contrary,  there  is  a  very  good 
panniculus  of  fat  in  the  majority  of  cases.  The  face  of  some  of  these 
subjects  presents  an  eczematous  or  lupoid  eruption.  The  lips  are 
thick;  the  conjunctivae  may  be  injected,  and  there  may  be  blepharitis 
or  phlyctenula  of  the  cornea.  Snuffles  and  nasal  catarrh  or  ozsena 
are  present.  The  majority  of  the  patients  are  mouth-breathers,  and 
suffer  from  adenoids  and  enlarged  tonsils.  In  some  there  is  chronic 
otitis  with  an  offensive  discharge.  There  is  a  fulness  about  the  neck 
due  to  enlarged  lymph-nodes.  The  body  may  present  skin  eruptions 
in  the  form  of  ecthyma  or  varieties  of  eczema.  The  general  surface 
is  in  other  cases  free  from  eruption,  is  pale,  and  has  a  transparent, 
marble-like  appearance,  showing  the  blue  veins  underneath.  Many 
of  these  patients  give  a  history  of  chronic  bronchitis.  In  others  the 
remains  of  old  suppurations  of  the  lymph-nodes  about  the  neck  are 
seen  in  the  form  of  livid  cicatrices.  If  the  long  bones  of  the  extremi- 
ties have  been  affected,  the  surface  of  the  skin  shows  either  old  or 
recent  bone  sinuses.  The  symptoms  in  most  cases  develop  first  on 
the  skin  and  mucous  membranes;  the  lymph-nodes  then  enlarge,  the 
bones  and  joints  are  next  involved,  and  finally,  if  the  case  does  not 
progress  favorably,  amyloid  degeneration  of  the  different  organs  and 
emaciation  develop  as  a  result  of  prolonged  suppuration.  In  all 
cases  the  changes  in  the  lymph-nocles  play  a  leading  part,  and  are 
characteristic. 

The  8hin. — In  the  unmixed  tuberculous  form  lupus  is  the  most 
common  skin  lesion;  in  another  form  there  is  the  so-called  scrofu- 
loderma of  Besnier.  Lichen  scrofulosorum,  with  the  characteristic 
enlargement  of  the  lymph-nodes,  is  another  form  of  skin  eruption. 
In  the  second  form  eczematous  and  acneform  eruptions  are  present. 
In  such  cases  the  skin  is  thickened  as  a  result  of  chronic  inflamma- 
tions. There  are  suppurating  rhagades  around  the  eyes,  mouth,  and 
anus,  and  ecthymatous  eruptions  may  be  present  on  the  trunk  and 
extremities.  A  form  of  scrofulous  ecthyma,  made  up  of  purple, 
painful  nodules  resembling  erythema  nodosum,  has  been  described 
by  Hutchinson.  Hebra  has  described  a  prurigo  of  the  scrofulous 
subject. 

Mucous  Membranes. — There  are  ulcerations  and  chronic  catarrh 


414  THE    SPECIFIC    IXFECIIOUS    DISEASES. 

of  the  uasal  and  bronchial  mncous  membranes,  and  in  some  cases 
ozsena  of  an  atrophic  character.  These  patients  have  adenoids  and 
enlarged  tonsils.  The  tonsils  are  favorite  seats  of  infection.  In 
other  cases  the  posterior  nasal  and  pharyngeal  catarrh  leads  to  retro- 
pharyngeal abscess,  or  caries  of  the  spine  may  cause  abscess  forma- 
tions in  the  retropharynx. 

The  Ears. — As  a  result  of  the  catarrh  of  the  nasopharynx  chronic 
otitis  may  develop.  When  otitis  follows  any  of  the  exanthemata  in 
a  patient  with  scrofulous  tendencies,  it  pursues  a  chronic  painless 
course.  Such  an  otitis  may  tend  to  tuberculous  disease  of  the  mas- 
toid with  sinus  thrombosis,  or  even  to  tuberculous  meningitis.  There 
is  pain  only  when  there  is  a  mixed  pyogenic  infection. 

The  Eye. — Chronic  eczema  of  the  lids,  blepharitis,  phlyctenula 
of  the  cornea,  and  keratitis  fasciculosa  are  seen.  The  phlyctenulse 
do  not  yield  readily  to  treatment.  Hypopyon  of  the  anterior  chamber 
may  also  be  present.  Trachoma  is  in  some  instances  of  a  tuberculous 
origin.     Lupus  of  the  conjunctiva  is  sometimes  present. 

Lymph-nodes. — The  tuberculous  and  tuberculo-pyogenic  forms  of 
enlargement  of  the  lymph-nodes  are  at  the  outset  similar.  The  pyo- 
genic varieties  are  associated  with  enlarged  tonsils  and  adenoids. 
The  skin  over  the  enlarged  nodes  may  remain  normal  for  months 
or  years,  or  in  both  the  tuberculous  and  pyogenic  varieties  it  may 
become  adherent,  red,  inflamed,  and  break  down.  The  lymph-nodes 
discharge,  leaving  suppurating  cicatricial  openings. 

Clinically,  infections  of  the  scalp  lead  to  enlargement  of  the 
lymph-nodes  of  the  neck  and  retromaxillary  region.  Those  of  the 
cornea,  iris,  and  ear  tend  to  enlarged  preauricular  nodes  and  to 
enlarged  nodes  of  the  submaxillary  region.  Infections  of  the  mouth 
and  tonsil  cause  enlarged  nodes  at  the  angle  of  the  jaw  and  beneath  it. 

Otitis  with  mastoid  disease  causes  enlargement  of  the  node  on  the 
point  of  the  mastoid.  The  lymphatics  of  the  gums  and  lips  are  con- 
nected with  the  nodes  of  the  submaxillary  region  and  angle  of  the 
jaw.  Affections  of  the  nose  will  cause  enlargement  of  the  glands  of 
the  neck  (Jacobi).  Lesions  of  the  fingers  Avill  result  in  enlargement 
of  the  cubital  and  axillary  nodes.  Infection  of  a  circumcision  wound 
or  balanitis  will  cause  enlargement  of  the  inguinal  lymph-nodes,  as 
will  also  infections  of  the  foot  and  knee. 

The  lymph-nodes  in  direct  line  are  always  involved ;  distant  ones 
are  never  infected  unless  there  is  infection  of  the  intermediate  nodes. 
It  was  formerly  believed  that  the  bronchial  nodes  were  particularly 
subject  to  infection.  Any  special  susceptibility  to  infection  shown 
by  these  nodes  is  due  to  their  location,  infectious  material  being  fre- 
quently present  in  their  vicinity. 

Cornet  found  the  bronchial  nodes  affected  in  103  out  of  126  cases 


SCBOFULA    OB    SCBOFULOSIS. 


415 


of  tuberculous  disease  occurring  before  the  completion  of  the  fifteenth 
year.  These  observations  confirm  the  statement  of  Henoch,  that  the 
bronchial  nodes  are  affected  in  the  majority  of  cases  of  tuberculous 
disease.  Becker,  Barthez  and  Rilliet,  Henoch,  and  JSTorthrup  have 
described  the  enlargement  of  bronchial  nodes.  According  to  Henoch, 
they  may,  even  if  tuberculous,  be  enlarged  without  involving  the  lung 
tissue.  By  pressing  on  the  vagi  they  may  cause  rapidity  of  pulse, 
and  if  on  the  recurrent  laryngeal  may  give  rise  to  spasmodic  dyspnoea 
or  to  a  croupy  cough.  Pressure  on  the  oesophagus  may  cause  dys- 
phagia ;  pressure  on  the  trachea  may  cause  inspiratory  dyspnoea ;  and 
pressure  on  the  pulmonary  veins,  hypersemia  of  the  lungs.  Henoch 
and  Baginsky  doubt  the  possibility  of  diagnosing  these  enlarged  nodes 
even  with  the  help  of  all  these  symptoms. 

Fig.  76. 


Tuberculosis  of  the  proximal  phalanx  of  the  index  finger  in  a  scrofulous  child  the  subject 
of  extensive  lupus  of  the  face  and  extremities   ("  Spina  ventosa"). 


These  nodes  may  retrograde  to  the  normal  size  (West)  or  they 
may  break  down  and  perforate  into  a  bronchus  or  the  trachea.  If 
they  perforate  into  the  pericardium,  pleura,  or  mediastinum,  inflam- 
mation results  at  these  points. 

The  mesenteric  lymph-nodes  may  enlarge  and  cause  pain  or  tuber- 
culous infection  of  the  peritoneum  (tabes  meseraica).  In  some  cases 
they  may  be  palpated  through  the  abdominal  wall. 

■  Bones  and  Joints. — The  extremities  of  the  long  bones  are  most 
frequently  the  seat  of  disease ;  the  diaphysis  rarely  so.  The  phalanges 
of  the  fingers,  the  toes,  the  radius,  the  ulna,  and  fibula,  are  affected 
in  the  order  of  naming.  The  joint-cavities  may  at  first  contain 
exudate  without  perforation  of  the  cartilage;  later,  pus  is  found  in 
the  cavity. 


416  THE    SPECIFIC    INFECTIOUS    DISEASES. 

All  of  the  structures  of  the  joint  are  involved,  and  the  joint  may 
eventually  be  destroyed.  Suppuration  of  a  chronic  nature  may.  as 
stated  elsewhere,  tend  to  amyloid  degeneration  of  the  liver  and  spleen. 

There  is,  in  addition,  a  progressive  ansemia.  The  temperature 
is  sometimes  raised  a  half  or  three-quarters  of  a  degree  above  the 
normal,  at  others  it  is  normal.  Exhausting  sweats  occur;  the  dis- 
turbances of  nutrition  become  in  some  cases  extreme.  There  may  be 
intestinal  diarrhoea. 

Course  and  Prognosis. — This  condition  is  not  necessarily  fatal. 
Many  eases  make  a  good  recovery  under  proper  management.  The 
disease  may  retrogTade  if  localized  to  certain  lymph-nodes  or  bone  foci. 

Diagnosis. — The  diagnosis  is  made  from  the  clinical  history; 
either  from  the  presence  of  the  tubercle  bacillus  in  the  pus  or  lesions 
of  the  disease,  or  in  those  forms  in  which  it  is  not  always  possible 
to  decide  whether  the  process  is  tuberculous  or  pyogenic  by  the  pres- 
ence of  the  tuberculin  reaction.  Most  striking  is  the  cutaneous  tuber- 
culin reaction  in  cases  in  which  there  is  a  so-called  tuberculo-toxic 
effect  on  the  tissues.  Here  we  have  latent  tuberculous  foci  out  of 
reach  of  observation.  The  tuberculous  toxins  permeate  the  tissues 
and  as  a  result  the  "  allergic  "  reaction  of  Von  Pirquet  is  very  marked ; 
more  so  than  in  cases  in  which  there  are  open  foci  and  tubercle  bacilli 
can  be  demonstrated.  The  reaction  is  large,  fully  10  cm.  in  diam- 
eter and  may  develop  to  necrotic  ulcers.  The  clinical  history  and 
blood  examination  will  be  of  service  in  differentiating  scrofulosis 
from  leukaemia,  pseudoleukfemia,  and  lymphomata  of  a  malignant 
nature  and  late  forms  of  hereditary  syphilis. 

Treatment. — The  treatment  of  scrofulosis  is  directed  toward  lim- 
iting if  possible  the  spread  of  the  infection,  preventing  reinfection 
of  the  patient,  and  instituting  local  treatment  of  the  lesion.  In  order 
that  the  disease  may  be  treated  successfully,  the  patient  should  be 
placed  in  good  hygienic  surroundings.  If  the  patient  is  in  the  city, 
removal  to  the  country  is  advisable.  The  food  should  be  plain  and 
nutritious ;  milk,  eggs,  meat,  vegetables,  and  cereals  should  form  the 
diet.  The  hygiene  of  the  skin  is  important.  Alkaline  or  sea  baths 
give  tone  to  the  skin.  Moderate  exercise  in  the  open  air  is  also  of 
great  service  in  correcting  the  anaemia  and  tendency  to  inaction  shown 
by  these  patients.  In  a  word,  the  patient  should  be  removed  from  the 
conditions  and  surroundings  which  originally  induced  the  infection. 

The  medical  treatment  is  limited  to  the  exhibition  of  such  tonics 
as  iron,  Fowler's  solution,  and  strychnine.  The  intestines  should 
receive  attention  during  the  administration  of  iron.  Fowler's  solu- 
tion gives  better  results  in  pyogenic  lymphadenitis  than  in  the  tuber- 
culous form.  The  syrup  of  ferric  iodide  in  full  doses  has  a  tonic 
effect  on  the  mucous  membranes.     Baginsky  advises  the  exhibition 


TUBERCULOSIS.  417 

of  preparations  of  thyroid  gland.  I  have  not  seen  any  markedly 
good  results  obtained  by  this  method  of  treatment. 

Cod-liver  oil  is  of  great  value  in  this  disease.  In  the  form  of 
emulsions  it  should  be  given  in  full  doses;  with  young  children  its 
use  must  sometimes  be  suspended  on  account  of  the  laxative  effect  on 
the  intestines.  The  tuberculin  treatment  by  very  small  hypodermic 
injections  of  Koch's  old  tuberculin  (%oooo  of  a  milligram  at  a  dose) 
causes  a  remarkable  improvement  in  these  cases.  The  complete 
restoration  is  indicated  by  an  absence  of  the  cutaneous  tuberculin 
reaction. 

The  local  skin  lesions  should  receive  appropriate  treatment,  as 
should  also  the  bones,  joints,  and  suppurating  lymph-nodes.  It  is 
not  within  the  province  of  this  work  to  enter  upon  the  surgical  details 
of  such  treatment. 

TUBERCULOSIS. 

Definition. — Tuberculosis  is  a  specific  infectious  disease  caused  by 
the  invasion  of  the  body  by  the  tubercle  bacillus. 

Clinical  Varieties.^ — The  tuberculous  infection  in  children  may  be 
general  or  local. 

If  general,  tuberculosis  may  manifest  itself  as  a  primary  infec- 
tion without  demonstrable  port  of  entry  or  it  may  be  secondary  to  a 
well-marked  primary  focus  of  infection. 

If  local  the  tuberculosis  may  remain  localized  at  the  primary  focus 
of  infection  or  may  extend  from  an  evident  port  of  entry  by  con- 
tinuity but  remain  localized. 

Clinically  it  is  not  always  possible  to  fix  on  the  primary  source 
of  infection,  but  postmortem  we  can  judge  which  focus  was  primary 
and  which  secondary,  especially  in  tuberculosis,  on  account  of  the 
anatomical  changes  in  the  retrogressive  lesions  such  as  cicatrization, 
calcification  and  encapsulation.  Thus  during  life  what  appears  as  a 
pulmonary  tuberculous  lesion  may  postmortem  reveal  itself  as  sec- 
ondary to  some  partially  cicatrized  ulcer  of  the  intestine  or  a  calcified 
mesenteric  lymph-node.  Moreover,  all  forms  of  tuberculosis  can  not 
be  definitely  classed  as  above.  There  are  especially  in  children  mixed 
forms.  All  tuberculosis  is  not  fatal  and  a  great  many  of  those 
affected  with  tuberculosis  may  never  have  shown  any  clinical  symp- 
toms. In  these  cases  of  healed  tuberculosis  the  lesion  is  revealed  by 
some  intercurrent  affection  or  accidental  death. 

Frequency  of  Tuberculosis  in  Childhood.- — Kossel  in  286  autopsies 

found  that  the  frequency  in  the  first  year  of  life  was  6  per  cent., 

from  the  first  to  the  fifth  year  8  per  cent.,  and  from  the  first  to  the 

tenth  year  36  per  cent.     The  frequency  of  tuberculosis  in  children 

27 


418 


THE    SPECIFIC    INFECTIOUS    DISEASES. 


varies  in  different  localities.  Thus  in  600  autopsies  in  children, 
Dennig  found  7  per  cent,  tuberculous;  Bollinger,  13.6  per  cent,  in 
500  autopsies;  Seidl,  27.9  per  cent,  in  64G  autopsies,  and  Raczynoki, 
18.3  per  cent,  in  3341  autopsies. 

From  a  study  of  all  tables  of  various  authors  we  may  say  that  in 
one  hundred  autopsies  on  children  29  or  30  either  died  of  tuberculosis 
or  that  it  was  found  as  a  concomitant  with  the  fatal  lesion.  Tuber- 
culosis under  the  age  of  three  months  is  rare  and  only  occasional  up 
to  the  twelfth  month  of  life.  The  frequency  then  rapidly  increases 
up  to  the  sixth  year  of  childhood,  after  which  it  decreases.  During 
the  first  four  weeks  of  infancy  Trepinski  found  no  deaths  from  tuber- 
culosis, from  the  fifth  to  the  ninth  week  one  case  which  may  have 
been  intra-uterine,  and  from  the  third  month  of  infancy  to  the  third 
year  of  childhood  a  gradually  increasing  ratio  until  the  fifth  year, 
when  a  decrease  was  noted.  In  short,  in  the  first  five  years  of  child- 
hood tuberculosis  is  found  in  fully  50  per  cent,  of  autopsies. 


Localization  of  the  Lesion  in  Tuberculous  Children. 


Bronchial 

Mesenteric 

Primary  In- 

Peri- 

Lymph 

Nodes. 

Nodes. 

testinal  T. 

toneum. 

Nodes. 

10.6 

Bovaird 

80% 
66% 

Carr 

16.6 

Dennig 

14.7 

21.3 

Grosser 

0.052 
0 

J 

Holt 

34.0 

Northrup 

7C 

% 

2.5 

Still 

72% 

23.4 

Trepinski 

90.4 

70.8 

17.4 

20.8 

17.9 

75.8 

Kossel 

40 
Including 
mesen- 
teric 
glands. 

9 

4.5 

51 

Pathogenesis.  Portals  of  Entry  and  Modes  of  Spread. — The  tuber- 
culous infection  may  be  aerogenous  (inhalation),  enterogenous  or 
alimentary  (inclusive  of  amygdalogenous),  lymphogenous  or  hsema- 
togenous,  dermogenous  (through  the  skin),  and  finally  hereditary  or 
congenital. 

Aerogenous  Form. — This  form  of  infection,  that  by  inhalation, 
by  far  the  most  frequent  form  in  the  adult,  is  also  the  commonest 
type  in  children.  Dennig  found  that  58  per  cent,  of  his  cases  of 
tuberculosis  occurred  in  families  in  whom  tuberculosis  was  prevalent. 
That  inhalation  tuberculous  infection  is  by  far  the  most  natural  form 
of  infection  in  children  is  proven  by  Lubarsch,  who  in  1820  autopsies 
found  tuberculosis  of  the  lungs,  and  bronchial  lymph-nodes  in  80  to 


TUBEBCULOSIS.  419 

96  per  cent,  of  the  cases.  Tubercle  bacilli  which  are  inhaled  may 
give  rise  to  intestinal  or  enterogenous  or  alimentary  infection  by 
gaining  access  to  the  alimentary  tract,  leaving  the  lungs  intact. 

Enterogenous  or  Alimentary  Form.- — This  variety  in  children 
takes  an  especial  rank  of  interest  on  account  of  the  possibility  of 
infection  through  the  milk  of  infected  cov^s.  This  question  has  been 
discussed  at  interminable  lenglh  and  an  attempt  has  been  made  to 
reconcile  the  varying  statistics  in  different  countries.  In  England 
it  is  considered  a  rather  frequent  form  of  infection.  Still  attributes 
25  per  cent,  of  his  cases  to  it.  Alimentary  infection  may  result  not 
only  from  the  ingestion  of  food  containing  tubercle  bacilli  but  also  by 
the  accidental  entrance  of  bacilli  into  the  mouth  and  thence  into  the 
alimentary  tract.  From  a  study  of  all  aspects  of  this  question  it 
would  appear  that  this  form  of  infection  undoubtedly  occurs  but  is 
exceedingly  rare. 

Tuberculosis  of  the  tonsils  which  is  included  under  the  general 
section  of  alimentary  form  of  infection  is  also  exceedingly  rare.  I 
have  published  a  case  of  primary  infection  of  the  tonsils  leading  to 
general  tuberculous  infection. 

Hwmatogenous  or  Lymphogenous  Form. — ^This  type  is  never  pri- 
mary but  occurs  through  the  breaking  down  of  some  tuberculous  focus, 
the  opening  up  of  a  bloodvessel  or  lymph-channel  and  the  spreading 
thus  of  tuberculous  material  through  the  circulation. 

Dermogenous  .Form. — This  form  is  seen  in  those  cases  of  tuber- 
culous cutaneous  disease  in  persons  whose  occupation  brings  them 
into  close  contact  with  tuberculous  tissues  or  animals.  Such  are  the 
autopsy  tubercles  and  the  cutaneous  tuberculosis  seen  among  butchers 
who  have  handled  tuberculous  meat.  It  is  therefore  scarcely  to  be 
considered  a  form  of  infection  in  children. 

Predisposing  Causes. — The  infectious  diseases  play  an  important 
role  as  predisposing  factors  in  tuberculosis.  Measles,  scarlet  fever, 
pertussis,  and  influenza,  by  lessening  the  resistance  of  the  economy 
and  impairing  the  integrity  of  the  air-passages,  favor  the  infection. 
Tuberculous  bronchopneumonia  occurs  under  these  conditions,  either 
because  the  tubercle  bacillus  was  present  in  the  body  before  the  infec- 
tion was  contracted  or  gained  access  subsequently  (Frankel).  In 
the  majority  of  cases  the  former  condition  is  the  rule.  Cold,  un- 
hygienic surroundings,  and  poor  food,  all  predispose  to  infection  as 
with  adults. 

Congenital  or  Foetal  Tuberculosis. — Foetal  infection  may  take 
place  either  through  an  infected  sperma  or  ovum  (germinative), 
through  the  placenta  (intra-uterine),  or  it  may  be  pseudo-congenital, 
that  is,  occur  very  shortly  after  birth.  The  last  form  has  caused  much 
discussion,  especially  in  cases  of  tuberculosis  in  which  the  infant  dies 


420  THE    SPECIFIC    INFECTIOUS    DISEASES. 

of  tuberculosis  some  weeks  after  birth.  It  is  then  an  open  question 
as  to  whether  the  infection  was  intra-uterine  or  post-partum.  There 
are  six  cases  of  undoubted  foetal  tuberculosis  in  the  literature  ( Jacobi, 
Birsch  Hirschfeld,  Lehman,  Schmorl,  Kockel  and  Wollstein), 

Of  the  cases  occurring  in  very  early  infancy  and  the  newborn, 
very  few  exist  in  the  literature  which  may  be  traced  to  intra-uterine 
infection,  and  are  therefore  to  be  considered  as  congenital.  In  these 
cases  the  children  died  so  soon  after  birth,  and  the  lesions  were  so  far 
advanced,  as  to  justify  this  assumption.  Tubercle  bacilli  are  exceed- 
ingly rare  in  the  testis  or  sperma,  and  it  is  questionable  whether  in 
such  cases  a  tuberculous  foetus  can  result.  In  the  human  subject 
there  is  not  one  authentic  example  of  infection  through  the  sperma 
of  a  tuberculous  individual.  Among  animals  we  find  that  there  are 
many  cases  of  observed  intra-uterine  infection ;  but  no  cases  in  the 
human  subject  of  infection  brought  about  by  insemination  of  the  male. 

The  spermatozoon  and  testis  may  contain  tubercle  bacilli  in  the 
absence  of  gross  tuberculous  lesions  of  the  organ  (l^akarai  and 
Kockel).  Tuberculosis  may  in  this  way  be  conveyed  into  the  uterus 
at  the  time  of  conception.  Jahni  and  Weigert  found  tubercle  bacilli 
also  in  the  Fallopian  tubes  of  women  dying  of  phthisis,  although 
there  were  no  gross  changes  in  the  tubes.  The  ovum  may  thus  convey 
tubercle  bacilli.  True  congenital  tuberculosis,  therefore,  in  the  sense 
just  intimated,  is  rare.  Foetal  tuberculosis  occurs,  as  shown  above, 
but  is  not  such  an  important  mode  of  infection  for  so  widespread  a 
disease  as  tuberculosis. 

There  is  another  form  of  foetal  tuberculosis,  and  that  is  the  so- 
called  bacillosis  or  bacillary  form.  In  this  form  the  foetus  is  found 
to  be  free  from  the  lesions  of  tuberculosis,  but  bacilli  are  found  in  the 
umbilical  vein  or  in  the  liver  or  in  the  foetal  organs.  Such  are  the 
cases,  including  that  of  Bugge,  of  foetal  tuberculosis  without  lesions. 
The  rarity  of  the  tuberculosis  of  the  foetus  is  due  to  the  fact  that 
bacillosis  of  the  mother  is  rare.  Bacilli  occurring  free  in  the  circu- 
lation in  advanced  phthisis  is  rare  in  itself;  and  they  soon  become 
localized  in  the  tissues.  The  placenta,  as  also  the  liver  of  the  foetus, 
acts  as  a  barrier  and  filter  of  the  tubercle  bacilli,  or  they  die  in  the 
blood-stream. 

The  characteristics  of  foetal  tubercle  are:  (1)  That  it  is  rarely 
pulmonary.  The  liver  is  frequently  afiected,  also  the  spleen,  kidneys, 
and  suprarenal  capsules ;  whereas  in  the  lungs  only  isolated  tubercles 
are  found.  (2)  Foetal  tissues  are  a  favorable  soil  for  tubercle.  (3) 
Giant  cells  are  wanting.  (4)  Bacilli  may  be  present  in  large  num- 
bers without  the  development  of  gross  lesions  (bacillosis  without 
lesions). 
'       Under  placental  infection  are  to  be  included  those  cases  in  which 


TUBERCULOSIS.  421 

the  tubercle  bacillus  has  been  found  in  the  blood  of  the  foetus  without 
accompanying  changes  in  the  organs  (Schmorl),  and  those  in  which 
tubercle  nodules  and  enlarged  lymph-nodes  have  been  found  at  birth 
(Landouzy  and  Lehman).  In  both  these  forms  of  tuberculous  infec- 
tion the  mother  had  suffered  from  acute  miliary  tuberculosis. 

Pulmonary  Tuberculosis. — Seventy  per  cent,  of  the  infants  and 
children  who  die  from  tuberculosis  show  lung-changes  (Dennig). 
Infection  first  occurs  through  the  respiratory  tract.  A  cheesy  lymph- 
node  may  burst  into  the  bronchi,  and  bacilli  may  thus  gain  access  to 
the  lung  alveoli  and  cause  changes,  as  they  do  in  the  adult  lung. 
Haematogenous  infection  occurs  through  the  bursting  of  a  small  tuber- 
culous nodule  into  a  bloodvessel,  thus  flooding  the  lung  with  infec- 
tious matter,  or  by  the  carrying  of  minute  emboli  of  this  material  to 
distant  parts  of  the  lung. 

Tuberculous  bronchial  lymph-nodes,  bone,  and  pleura  may  also 
give  rise  to  infection  of  the  lung  through  the  lymph-channels.  The 
part  played  by  the  infectious  diseases  in  its  dissemination  has  been 
already  mentioned. 

Morbid  Anatomy. — The  three  principal  forms  of  tuberculosis  of 
the  lungs  which  occur  in  infants  and  children  are : 

Miliary  Form. — The  miliary  form,  which  is  characterized  by  the 
eruption  of  miliary  tubercles  throughout  the  lung.  The  lung  is  on 
section  found  to  be  dark  red,  hypersemic,  and  to  contain  less  air  than 
the  normal  lung.  The  bronchial  mucous  membrane  is  hypersemic 
and  covered  with  blood  and  mucus. 

Cheesy  or  Cheesy  Ulcerative  Form. — The  cheesy  or  cheesy  ulcera- 
tive form,  also  called  florid  phthisis,  takes  the  form  of  cheesy  lobar  or 
lobular  pneumonia.  In  recent  cases  the  lung  is  grayish  red,  and 
there  are  areas  which  rapidly  become  cheesy,  and  are  not  encapsu- 
lated. These  may  coalesce,  involving  the  greater  part  of  a  lobe  in 
the  process.  Small  cavities  are  frequent,  large  ones  rare.  The 
cheesy  ulcerative  form  occurs  as  a  result  of  the  aspiration  of  large 
numbers  of  tubercle  bacilli. 

Chronic  Form. — The  chronic  form,  which  is  a  cheesy  fibroua 
bronchopneumonia,  is  essentially  a  tuberculous  bronchopneumonia. 
Round  cheesy  nodules  are  found  surrounded  by  a  fibrocellular  zone 
resulting  from  the  destruction  of  extensive  areas  of  lung-tissue.  The 
pulmonary  pleura  is  thickened.  The  bloodvessels  participate  in  the 
process.  There  is  endarteritis  with  miliary  tubercle  in  the  walls  of 
the  bloodvessels,  and  there  may  be  thrombosis.  The  tubercles  may 
burst  into  the  interior  of  the  bloodvessels.  The  bronchi,  trachea,  and 
larynx  may  be  affected.  There  are  ulcerations  of  the  mucous  mem- 
brane and  destruction  of  cartilage.  The  bronchial  lymph-nodes  or 
glands  are  enlarged  and  infected  in  most  cases  of  tuberculosis  of  the 


422  THE    SPECIFIC    INFECTIOUS    DISEASES. 

lungs  in  children.  Henoch  has,  however,  shown  that  the  bronchial 
nodes  may  be  tuberculous  and  greatly  enlarged  without  involvement 
of  the  lung-tissues.  jSTorthrup  found  the  bronchial  lymph-nodes 
affected  in  125  consecutive  autopsies.  The  whole  node  is  converted 
into  a  cheesy  mass,  which  may  soften  and  break  down.  If  there  is  a 
perforation  into  a  bronchus,  masses  of  bacilli  may  be  discharged  into 
the  lung.  Perforation  into  the  bloodvessels  may  also  occur.  The 
nodes  may  form  small  masses  or  large  mediastinal  tumors  at  the  root 
of  the  lung. 

Localization. — The  apices  of  the  lungs  of  infants  and  children  are 
not  as  in  adults  the  region  most  frequently  affected  by  tuberculosis. 
The  first  change  may  appear  in  the  lower  lobe  or  the  lower  portion 
of  the  upper  lobe,  and  spread  thence.  This  is  accounted  for  by  the 
miliary  character  of  the  affection  in  the  lungs  of  infants  and  children 
(Rindfleisch),  and  also  by  the  fact  that  in  many  cases  the  process 
spreads  from  the  bronchial  nodes  or  glands  to  adjacent  parts  (Weigert) . 

Symptoms. — The  symptoms  of  tuberculosis  of  the  lungs  in  infants 
and  young  children  are  not  so  characteristic  as  in  the  adult,  nor  is 
there  a  gTadual  development  of  the  symptoms  pointing  to  involvement 
of  the  lungs.  After  the  fifth  year  of  life  the  symptoms  closely  resem- 
ble those  seen  in  the  adult.  As  regards  infants,  we  shall  describe 
only  clinical  types  of  the  disease.     Even  these  exhibit  many  varieties, 

Henoch  has  described  forms  of  tuberculosis  in  infants  which 
closely  resemble  cases  of  marasmus  due  to  gastro-enteric  disease.  In 
many  of  them  there  are  steady  emaciation  and  progressive  muscular 
weakness ;  the  infant  lies  helpless ;  the  abdomen  is  retracted ;  the 
eyes  may  present  a  conjunctivitis;  the  cervical,  axillary,  and  inguinal 
glands  may  be  slightly  enlarged;  there  is  constipation  alternating 
with  diarrhoea ;  the  skin  is  easily  inflamed  and  abscesses  may  form. 
In  the  terminal  period  vomiting  sets  in.  The  lungs  throughout  the 
course  of  the  disease  may  present  few  signs,  or  there  may  be  evidences 
of  a  general  bronchitis.  In  these  slowly  emaciating  infants  there  is 
no  cough  of  sufficient  severity  to  indicate  involvement  of  the  lung. 
The  terminal  stage  may  present  cerebral  symptoms  of  a  mild  type, 
such  as  rigidity  of  the  neck,  with  periods  of  stupidity  alternating 
with  irritability.  The  infants  die  with  a  progressive  loss  of  flesh 
and  streng-th.  The  temperature  is  for  days  normal  or  a  little  above 
normal.  In  other  ty])es  the  disease  is  masked  by  an  acute  or  sub- 
acute bronehoi)]icninonia.  In  these  cases  the  infant,  after  suffering 
from  exposure  or  some  infectious  disease,  suddenly  exhibits  all  the 
signs  of  a  bronchopneumonia.  There  are  severe  cough,  high  tem- 
perature, dyspnoea,  and  cyanosis,  as  in  the  ordinary  bronchopneu- 
monia. Death  may  ensue  in  a  few  days  or  in  a  week.  In  other 
forms  fatal  results  take  place  after  several  weeks,  with  symptoms 


TUBEBCULOSIS.  423 

closely  resembling  those  of  a  persistent  broncliopneiinionia  of  the 
ordinary  non-tuberculous  variety. 

In  other  cases  the  symptoms  of  an  acute  bronchopneumonia  are 
present,  sometimes  complicated  with  empyema.  Evacuation  of  the 
pus  is  followed  by  apparent  improvement,  and  the  empyema  may  even 
heal,  but  the  infant  or  child  gradually  emaciates,  and  the  cough, 
which  may  have  abated,  becomes  aggravated.  Examination  of  the 
chest  reveals  new  areas  of  lung  involvement.  In  these  cases  the  pus 
does  not  always  contain  the  tubercle  bacilli.  The  empyema  may  be 
the  result  of  mixed  infection,  and  the  pus  may  contain  only  simple 
streptococci,  the  physician  being  frequently  misled  as  to  the  true  con- 
dition. Many  forms  of  tuberculosis  of  the  lungs  in  infants  and 
children  may  cause  death  with  the  terminal  symptoms  of  tuberculous 
meningitis. 

Especially  characteristic  in  older  children,  as  compared  with  the 
adult,  are- those  cases  of  tuberculosis  of  the  lung  which  follow  some 
slight  injury,  blow,  or  exposure,  and  in  which  there  are  for  weeks 
no  signs  in  the  lung  or  elsewhere  to  account  for  the  gradual  emacia- 
tion and  intermittent  or  remittent  temperature.  After  a  variable 
length  of  time  signs  of  involvement  are  detected  at  one  apex,  or 
posteriorly  over  the  base  or  mid-area  of  the  lung.  Even  then  the 
cough  may  be  absent  and  no  sputum  be  expectorated.  The  child  then 
has  intervals  of  stupidity;  there  is  delirium  at  night  accompanied 
by  the  typical  hydrocephalic  cry.  Irritability  of  temper  is  marked, 
the  emaciation  is  very  rapid,  and  coma  and  death  with  terminal  paral- 
yses show  that  the  infection  has  involved  the  cerebral  meninges. 

Temperature. — The  temperature  is  irregular  in  course.  It  may 
be  normal  for  a  few  days,  after  which  it  rises  one  or  two  degrees 
daily  in  the  afternoon  and  falls  to  the  normal  toward  morning. 

Hcemoptysis. — Haemoptysis  is  very  rare  in  infants.  Henoch 
has  seen  3  cases  in  young  infants  and  1  in  a  child  of  two  years.  Acker 
has  reported  a  case  in  a  child  of  three  years.  I  have  seen  several 
cases  in  children  of  more  than  six  years  of  age. 

Sputum. — Infants  do  not  expectorate.  At  most  a  frothy  mucus 
collects  around  the  orifice  of  the  mouth  after  a  coughing  spell.  Even 
older  children  expectorate  very  little,  and  must  be  taught  to  do  so. 

Holt  has  recently  devised  a  method  by  which  tubercle  bacilli  may 
be  obtained  in  sputum  adherent  to  the  epiglottis  by  carrying  a  small 
cotton  swab  into  the  fauces  and  catching  the  mucus  from  the  epiglottis 
in  the  act  of  coughing. 

Course,^ — Up  to  the  second  year  of  life,  the  course  of  tuberculosis 
of  the  lungs  is  generally  acute  (Henoch).  The  disease  may  pursue 
a  subacute  course,  but  it  is  rarely  as  prolonged  as  in  the  adult.     In 


424 


TRE    SPECIFIC    INFECTIOUS    DISEASES. 


children  beyond  tlie  fifth  year  its  course  closely  resembles  that  taken 
in  the  adult. 

Diagnosis. — The  diagnosis  of  tuberculosis  of  the  lung  in  infancy 
and  early  childhood  must,  for  the  most  part,  be  made  from  the  his- 
tory of  the  case.  In  many  of  the  cases  the  physical  signs  in  no  way 
differ  from  those  seen  in  non-tuberculous  diseases.  Cases  in  which 
marked  consolidation  of  the  lung  persists,  with  progressive  emacia- 
tion, and  cases  in  which  auscultation  reveals  the  presence  of  cavities, 
are  certainly  suspicious.  There  is  no  reliable  method  of  determining 
the  nature  of  an  acutely  developing  bronchopneumonia ;  the  detection 
of  the  tubercle  bacillus  in  the  vomit,  in  the  faces,  or  in  the  exudate 
of  a  complicating  pleurisy  or  empyema,  is  of  diagnostic  aid. 

Fig.  77. 


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Subcutaneous  injection,  tubercuUn  negative  at  first  and  positive  on  the  second  injec- 
tion.    Case  of  peritoneal  tuberculosis. 

The  existence  of  enlarged  lymph-nodes  in  the  mediastinum  or  the 
root  of  the  lung  is,  according  to  some  authors,  revealed  by  symptoms 
of  pressure.  Pressure  on  the  bronchi  may  give  rise  to  dyspnoea ;  on 
the  large  veins,  to  nervous  congestion  and  cyanosis,  or  oedema  of  the 
lungs ;  on  the  recurrent  laryngeal  nerves,  to  asthma  or  laryngospasm ; 
on  the  oesophagus  to  dysphagia.  Although  in  exceptional  cases  such 
symptoms  may  be  thus  correctly  interpreted,  I  believe  with  Henoch 
that  diagnosis  of  these  enlarged  nodes  during  life  is  highly  uncertain. 

TuBEECULiN  Test. — The  tuberculin  test  for  tuberculosis  will  aid 
in  corroborating  the  diagnosis  in  any  particular  case.  There  are 
three  well  recognized  tuberculin  tests:  The  subcutaneous  test,  the 
conjunctival  test  of  Calmette  and  Wolf-Eissner,  and  the  cutaneous 
scarification  test  of  von  Pirquet.  There  is  also  a  fourth  test,  the 
so-called  Moro  inunction  test,  but  this  is  not  in  general  use. 


PLATE  XXIV 


Cutaneous   Reaction  with  Tuberculin.     Case  of  glandular 
tuberculosis  in  a  child  six  years  of  age. 


TUBERCULOSIS. 


425 


Fig.  78. 


Subcutaneous  Test. — The  subcutaneous  test  consists  of  injecting 
underneath  the  skin  0.1  to  0.5  of  a  milligram  of  old  tuberculin  Koch. 
Within  24  hours  there  occurs  a  so-called  reaction  or  rise  of  tempera- 
ture to  a  variable  extent ;  after  a  short  time  the  temperature  again 
falls  to  the  normal  without  further  symptoms  (Fig.  77). 

Conjunctival  Test. — The  conjunctival  test  is  not  generallv  applied 
in  children  on  account  of  the  untoward  effects  which  may  follow  its 
application  in  certain  cases.  When  a  drop  of  tuberculin  solution  is 
instilled  into  the  eye  of  an  individual  in  whom 
there  is  tuberculous  virus,  there  occurs  in  from 
four  to  twenty-four  hours  an  injection  of  the  pal- 
pebral conjunctiva,  semilunar  fold,  caruncle  and 
orbital  conjunctiva,  which  varies  in  intensity  in 
different  individuals.  It  is  attended  by  lachry- 
mation  and  a  fibrinous  or  fibrino-purulent  exu- 
date. This  may  go  on  to  profuse  suppuration 
attended  by  very  marked  swelling  of  the  tissues  of 
the  orbit.  This  reaction  reaches  its  maximum  in 
24  to  48  hours  and  then  gradually  subsides. 

Cutaneous  Scarification  Test. — The  cutaneous 
scarification  test  consists  in  scarifying  the  skin  by 
means  of  a  so-called  borer.  The  skin  of  the 
left  forearm  on  the  anterior  and  radial  aspect  is 
cleansed  with  ether  and  three  punctate  scarifica- 
tions are  made  by  means  of  the  V.  Pirquet  (Fig. 
78).  This  instrument  is  shaped  very  much  like 
a  watchmaker's  screw-driver.  It  is  held  perpen- 
dicularly to  the  arm  and  with  a  twisting,  rotary 
motion  in  the  manner  in  which  the  watch-maker 
screws  the  screw  into  its  socket  the  scarifications, 
three  in  number,  are  rapidly  made.  Two  of  the 
scarifications  are  inoculated  with  a  minute  drop  of 
old  tuberculin;  the  third  scarification  is  left  untouched  for  control. 
After  three  or  four  seconds  the  tuberculin  is  wiped  off  the  scarifica- 
tions. In  from  five  to  twenty-four  hours  there  develops  a  piuk  areola 
around  the  scarifications  inoculated  with  tuberculin.  This  areola 
ranges  from  five  to  ten  millimetres  in  diameter  and  is  somewhat  infil- 
trated and  papular.  The  extent  of  the  areola  and  infiltration  varies 
in  different  individuals.  It  fades  after  a  variable  length  of  time, 
persisting  longest  in  scrofulous  individuals  or  in  those  having  abun- 
dant antibody,  as  it  is  called,  in  the  blood  (Plate  XXIV.). 

This  reaction  of  Yon  Pirquet  is  certainly  clinically  the  most 
useful  of  all  the  so-called  tuberculin  tests.  It  is  never  followed  by 
any  untoward  results.     It  is  absent  in  many  cases  before  death,  and 


Borer  for  making 
the  cutaneous  tuber- 
culin test. 


426  THE    SPECIFIC    INFECTIOUS    DISEASES. 

in  cases  of  measles  in  the  first  week  of  the  period  of  Koplik  spots  and 
the  skin  exanthema. 

The  principle  of  all  the  reactions  has  been  explained  by  Von 
Pirquet  on  the  theory  of  so-called  "allergic"  (allergistic  reaction), 
that  is  to  say,  when  an  individual  contracts  tuberculosis,  there  develops 
a  hyper-sensitiveness  of  the  tissue-cells  to  the  poison  of  the  tubercle 
bacillus ;  in  other  words,  there  is  an  acquired  immunity  to  the  tubercle 
poison  against  which  the  system  attempts  to  protect  itself.  This 
acquired  immunity  is  developed  by  the  creation  in  the  blood  of  a 
so-called  antibody  or  "  antigone."  It  is  sometimes  necessary  in  the 
presence  of  a  negative  result  to  repeat  the  test.  A  test  negative  on 
the  first  trial  may  result  positive  on  the  second  inoculation.  These 
cases  include  many  so-called  latent  cases  of  tuberculosis. 

Treatment. — From  a  study  of  the  symptomatology  it  will  be  seen 
that  the  treatment  of  tuberculosis  of  the  lung  in  young  infants  and 
children  must  be  simply  symptomatic  and  will  not  differ  materially 
from  that  of  the  adult.  A  case  of  suspected  tuberculosis  should  be 
isolated  from  other  children.  The  fever  needs  little  attention  if  it 
remains  low ;  if  high,  it  is  treated  as  in  a  case  of  simple  bronchopneu- 
monia. The  cough  and  restlessness  are  also  treated  symptomatically. 
The  feeding  and  general  nutrition  are  of  extreme  importance  as  well 
as  change  of  climate  and  hygienic  surroundings. 

Tuberculosis  of  the  Peritoneum  {Tuberculous  Peritonitis). — 
Occurrence. — According  to  the  statistics  of  Dennij,  Miiller,  Biedert, 
and  Simmonds,  tuberculous  peritonitis  occurs  in  from  8  to  21  per 
cent,  of  all  the  cases  of  tuberculous  disease.  Sixty-five  per  cent,  of 
the  cases  operated  on  by  Herzfeld  were  under  the  age  of  fifteen  years. 
The  frequency  varies  in  different  localities. 

Acute  tuberculosis  of  the  peritoneum  is  seen  in  acute  phthisis  as 
a  complication,  when  there  may  be  also  an  exudate  with  miliary  tuber- 
culosis of  the  peritoneum.  This  form  of  peritoneal  tuberculosis  is 
of  no  clinical  interest. 

Chronic  Form. — This  is  the  form  under  consideration.  It  is  rare 
in  the  newborn ;  in  a  statistic  of  100  cases  Still  found  the  disease  most 
frequent  from  the  second  to  the  fifth  year  of  life.  'Next  in  frequency 
was  the  period  of  five  to  ten  years. 

Etiology,- — Tuberculous  peritonitis  is  rarely  if  ever  primary, 
although  such  cases  have  been  described  by  Henoch  and  Miiller. 
The  peritoneum  may  become  infected  through  the  blood-channels 
(ha'matogenous)  ;  under  these  conditions  tuberculosis  of  the  perito- 
neum is  simply  a  feature  of  the  manifestation  of  acute  miliary  tuber- 
culosis. The  peritoneum  may  become  infected  through  the  lymphatics 
or  lymph  channels  (lymphogenous).  Under  these  conditions  it  is 
the  result  of  infection  from  adjacent  organs,  such  as  the  intestines. 


TUBEECULOSIS.  427 

the  genito-nriiiary  tract,  the  mesenteric,  peritoneal,  retroperitoneal,  or 
l>ronchial,  lymph-nodes,  and  the  vertebrse  and  pleura. 

Morbid  Anatomy.- — There  are,  according  to  Herzfeld,  three  main 
forms  of  tubercnlons  peritonitis:  the  miliary,  submiliary  or  exudative 
form ;  the  nodular  or  sclerosing  form ;  and  the  adhesive  form. 

The  Miliary,  Suhmiliary,  and  Exudative  Form. — In  this  form 
there  is  an  eruption  on  the  jjeritoneal  surface,  of  gray,  transparent 
tubercles  of  varying  sizes.  The  intestinal  coils  are  covered  with 
fibrin,  and  are  slightly  adherent  to  one  another.  There  is  a  clear 
serous,  serofibrinous,  serojDurulent,  or  even  ichorous  exudate  (mixed 
infection). 

The  Nodular  or  Sclerosing  Form. — In  this  form  the  quantity  of 
the  exudate  in  the  abdominal  cavity  is  small.  The  omentum  is  con- 
verted into  a  solid  cylindrical  mass,  containing  tumors  of  a  tuber- 
culous nature  as  large  as  an  apple.  The  mesentery  is  thickened  and 
covered  with  tubercles.  The  intestinal  wall  is  thickened  and  covered 
with  gray  or  grayish-yellow  tubercles,  which  may  attain  the  size  of 
tumors.  The  coils  of  gut  are  adherent,  and  the  whole  peritoneal 
cavity  may  be  obliterated. 

The  Adhesive  Form. — In  this  form  the  intestines  form  an  adher- 
ent mass,  witb  masses  of  exudate  between  the  coils  of  gut,  forming 
pseudocysts.  This  exudate  may  be  of  a  puriform  nature.  AggTe- 
gations  of  tubercles  between  the  coils  of  gut  break  down  and  perforate 
into  the  gut,  or  become  adherent  to  the  abdominal  wall  and  perforate 
externally,  forming  intestinal  or  abdominal  fistulse.  Perforation 
may  thus  occur  in  the  absence  of  any  real  ulceration  on  the  mucous 
membrane  of  the  gut. 

In  addition  to  the  above  principal  forms  of  tuberculous  perito- 
nitis, mixed  forms  occur. 

The  exudate  in  the  peritoneal  cavity  may  be  purely  serous 
(ascites),  or  the  serum  may,  as  in  a  case  which  I  observed,  have  a 
chylous  appearance,  due  to  the  admixture  of  fat.  In  other  forms  the 
exudate  may  be  seropurulent,  hemorrhagic,  or,  in  mixed  infections, 
putrid.'  In  the  purely  ascitic  variety  the  fluid  is  free ;  in  the  puru- 
lent form,  it  is  frequently  sacculated  between  the  adhesions  on  the 
coils  of  gut. 

Symptoms.— The  disease  is,  as  a  rule,  insidious  and  slow  in  devel- 
opment. The  stage  of  abdominal  distention  has  usually  been  reached 
when  the  patient  is  first  brought  to  the  physician.  The  history  shows 
that  the  child  has  been  for  some  time  gradually  losing  weight,  that 
the  appetite  is  capricious,  and  that  there  have  been  attacks  of  abdom- 
inal pain.  This  pain  vasij  be  localized  or  radiate  from  one  point, 
may  be  constant,  or  may  resemble  visceral  neuralgia.  Sometimes 
there  is  no  history  of  pain,  but  it  may  be  detected  by  pressure  on 


428 


THE    SPECIFIC    IXFECTIOUS    DISEASES. 


parts  of  the  abdomen.  There  may  be  a  slight  rise  of  temperature 
toward  evening  (Fig.  79)  ;  diarrhoea  may  alternate  with  constipation. 
The  abdominal  distention  is  the  leading  feature.  It  may  take  the 
form  of  a  uniform  ascitic  accumulation  (Fig.  80)  ;  the  surface  of 
the  abdomen  may  be  uneven  and  irregular  (Fig.  81),  and  tumors 
with  cystic  formation  may  be  felt  through  the  abdominal  walls. 

The  movements,  which  are  rich  in  fat,  sometimes  resemble  icteric 
evacuations.  This  condition  was  formerly  considered  pathognomonic 
of  tuberculous  peritonitis  (Biedert,  Conitzer). 

Vomiting  of  f  »cal  or  biliary  matter  resembling  that  seen  in  appen- 
dicitis may  occur. 

In  marked  contrast  with  these  is  a  form  which  in  its  acute  onset 
may  simulate  acute  perforative  peritonitis.  In  this  variety  the 
tubercle  mass  may  cause  perforation  either  of  the  appendix  or  the 

Fig.  79. 


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Tuberculous  peritonitis.     Female  child,  five  years  of  age.     Ten  days  of  her  temperature 
immediately  preceding  operation    (laparotomy). 


intestine.  Symptoms  of  acute  perforative  peritonitis  which  in  every 
way  resemble  those  of  appendicitis  set  in.  It  is  only  by  resort  to 
laparotomy  that  the  nature  of  the  affection  can  be  discovered. 

Physical  Signs. — The  physical  signs  in  the  miliary  and  the  nodular 
forms  are  due  to  the  presence  of  free  fluid  in  the  abdominal  cavity. 
If  ascites  is  present,  there  will  be  the  percussion-wave,  the  flatness  in 
the  flanks,  and  change  of  tympanitic  area  will  occur  with  change  in 
the  position  of  the  patient.  If  adhesions  are  present  and  there  are 
encapsulations  of  fluid,  the  signs  will  not  vary  on  changing  the  posi- 
tion of  the  patient.  On  the  other  hand,  in  the  adhesive  form  there 
will  be  evidences  of  tumor  masses  in  the  abdominal  cavity,  cystic  for- 
mations caused  by  the  encapsulated  exudate,  and  little  or  no  fluid. 

In  cases  of  adhesions  in  tuberculous  peritonitis  of  the  miliary 
form,  the  fact  that  when  the  patient  is  in  the  recumbent  position  the 
coils  of  gut  may  here  and  there  be  seen  outlined  over  the  abdominal 
parietes,  is  of  diagnostic  value  (Fig.  81).  I  was  able  by  this  means 
to  confirm  the  diagnosis  of  adhesions  in  one  such  case,  and  have 
detected  them  clinically  in  other  cases  in  which  this  form  of  perito- 
nitis had  been  diagnosed. 


TUBERCULOSIS. 


429 


Tiie  liver  may  be  enlarged  as  a  result  of  amyloid  degeneration  or 
tuberculous  interstitial  hepatitis. 

The  spleen  may  be  enlarged  as  a  result  of  amyloid  degeneration. 

Rectal  examination   may   reveal  miliary  nodules   or  peritoneal 
masses  palpable  through  the  walls  of  the  rectum. 

Diagnosis. — The  diagnosis  is  based  on  the  slovv^  and  insidious 
onset,  the  colicky  abdominal  pains,  abdominal  tenderness  on  palpa- 
tion, the  presence  of  ascites  or  tumor 
masses,  constipation  alternating  with 
diarrhoea,  progressive  loss  of  strength, 
intermittent  fever  or  slight  rise  of  tem- 
perature in  the  evenings,  and  the  pres- 
ence of  tuberculosis  in  other  organs. 
At  the  outset  tuberculous  infection  in 
other  parts  of  the  body  may  be  difficult 
of  detection.  A  rectal  examination 
should  always  be  made.  This  form 
of  peritonitis  should  be  differentiated 
from  the  non-tuberculous  form.  Inas- 
much as  some  authors,  notably  linger 
and  l^othnagel,  doubt  the  occurrence 
of  idiopathic  non-tuberculous  perito- 
nitis, caution  should  be  exercised  in 
making  a  diagnosis  of  simple  chronic 
peritonitis.  Absence  of  emaciation  and 
retrogression  of  symptoms  by  no  means 
prove  that  the  disease  may  not  have 
been  tuberculous,  since  some  forms  of 
tuberculosis  of  the  peritoneum  present 
such  peculiarities. 

This  form  of  peritonitis  must  also 
be  differentiated  from  cirrhosis  of  the 
liver,  new  growths,  cardiac  and  renal 
affections. 

In  some  forms  of  tuberculous  peritonitis,  especially  of  the  miliary 
type,  the  child  will  fail  to  show  a  temperature  above  the  normal  for 
weeks,  and,  being  in  tolerably  good  condition,  the  question  will  arise 
as  to  the  nature  of  the  abdominal  process.  In  these  cases  a  diagnosis 
is  facilitated  by  the  use  of  tuberculin.  A  reaction  may  be  thus 
attained  varying  from  a  degree  or  more  above  the  normal.  The 
patient  is  placed  in  bed,  the  temperature  previously  observed  every 
three  hours  for  a  few  days,  and  is  then  given  subcutaneously  0.25 
milligramme  of  tuberculin.  If  no  reaction  takes  place,  0.50  milli- 
gramme is  given  after  a  few  days.     The  dose  may  be  increased  to  a 


Uniform  abdominal  distention  due 
to  ascites  of  tuberculous  peritonitis  ; 
enlarged  spleen. 


430 


THE    SPECIFIC   INFECTIOUS    DISEASES. 


milligramme  with  older  children.  A  reaction  takes  place,  if  the 
process  is  tuberculous,  within  twent j-four  hours ;  though  I  have  seen 
it  delayed  for  forty-eight  hours  (Fig.  77).  The  cutaneous  tuber- 
culin test  is  also  applicable  in  these  cases. 


Fig.  8L 


Tuberculous  peritonitis,  miliary  form,  female  child,  five  years  of  age.     Irregular  contour 
of  abdominal  parietes  in  the  recumbent  posture,  showing  intestinal  agglutination. 

Course. — The  course  of  the  disease  is  chronic.  Frequently  the 
symptoms  retrograde  and  there  is  an  apparent  recovery.  The  ascites 
may  at  times  diminish,  and  again  increase.  The  chronic  forms 
unless  operated  upon  lead  to  the  formation  of  abdominal  fistulse,  to 
perforative  peritonitis,  to  tuberculosis  of  the  organs,  and  to  amyloid 
degeneration  of  the  liver  and  spleen,  with  emaciation,  exhaustion, 
and  death. 

Treatment. — Laparotomy,  when  there  is  no  advanced  tuberculosis 
in  other  organs,  is,  according  to  Herzfeld,  curative  in  54  per  cent, 
of  cases.  In  a  series  of  29  cases  of  all  ages  operated  upon  by 
him,  19  were  under  the  age  of  fifteen  years.     With  operative  treat- 


TUBERCULOSIS. 


431 


ment  must  also  be  combined  the  medicinal  and  hygienic  treatment 
suitable  to  cases  of  pulmonary  or  local  tuberculosis.  On  the  other 
hand,  in  the  forms  which  resemble  cases  of  tabes  mesenterica,  in 
which  emaciation  and  cachexia  are  present  before  much  exudate  is 
formed,  it  is  difficult  to  decide  as  to  the  proj)riety  of  operative  meas- 
ures, especially  if  diarrhoea  be  present.  In  these  proper  feeding 
should  be  begun  and  the  condition  of  the  patient  improved  before 
laparotomy  is  attempted. 

Tuberculosis  of  the  Mesenteric  Glands  (Tabes  Mesenteric  a).- — 
Definition. — This  term  is  applied  to  a  set  of  cases  in  which  we  can 
clinically  detect  enlargement  of  the  mesenteric  lymph-nodes.  There 
is  wasting  and  fever  without  tuberculosis  of  the  peritoneum.     As  a 

Fig.  82. 


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Tuberculin  reaction.     Miliary  form  of  tuberculous  peritonitis.     Diagnosis  confirmed  by 
operation.     Boy  four  years  of  age. 


clinical  entity  this  condition  is  not  common  inasmuch  as  in  60  per 
cent,  of  all  cases  of  tuberculosis  there  is  associated  tuberculosis  of  the 
mesenteric  lymph-nodes. 

Pathogenesis. — In  a  recent  inquiry  into  the  frequency  and  types 
of  primary  tuberculosis  of  the  mesenteric  lymph-nodes,  Hess  found 
that  in  60  per  cent,  of  the  cases  the  disease  was  caused  by  the  bovine 
type  of  tubercle  bacilli.  This  type  was  most  frequent  in  children. 
In  both  children  and  adults  these  lymph-nodes  may  heal  or  retro- 
grade. In  two  cases  reported  by  Hess  the  bacilli  were  of  the  human 
type. 

Symptoms. — In  most  of  the  cases  there  have  been  progressive  wast- 
ing and  colicy  pains  referred  to  the  abdomen.  These  symptoms  may 
extend  over  weeks  or  months.  The  pain  is  not  severe,  the  children 
are  ill-tempered,  the  appetite  is  capricious,  there  is  diarrhoea  alter- 
nating with  constipation,  and  a.  low,  irregular  type  of  temperature. 

Diagnosis. — The  only  positive  evidence  of  the  disease  is  the  pres- 
ence of  lymph-nodes  on  either  side  of  the  spine.  They  may  be  pal- 
pated at  the  level  of  the  umbilicus. 


432  TRE    SPECIFIC    INFECTIOUS    DISEASES. 

Prognosis. — The  prognosis  is  good.  I  have  seen  cases  recover 
completely. 

Treatment. — The  treatment  consists  in  a  study  of  correct  diet, 
hygienic  surroundings  and  open-air  life.  There  is  no  indication  in 
the  absence  of  complications  for  surgical  interference. 

Other  Forms  of  Tuberculosis. — Tuberculosis  of  the  Larynx. — Tu- 
berculosis of  the  larynx  is  rare  in  children.  It  occurs  in  from  3  to 
4  per  cent,  of  the  total  number  of  cases  of  tuberculosis  (Reiner, 
Steffen,  Barthez,  Rilliet).  Demme  has  reported  a  case  in  a  child  of 
four  and  one-half  years. 

Tuberculosis  of  the  Pleura  and  Pericardium. — Primary  tuberculosis 
of  the  pleura  is  rare.  Dennig  reports  that  it  occurred  as  a  feature 
of  general  tuberculosis  in  14  per  cent,  of  his  cases.  Pericarditis  of 
the  tuberculous  variety  occurs  in  only  3  per  cent,  of  the  cases  of  gen- 
eral tuberculosis. 

Tuberculosis  of  the  Heart. — Tuberculosis  of  the  heart  muscle  is 
very  uncommon.  Sanger  reports  a  case  in  a  child  of  nine  months,  and 
Demme  one  in  a  patient  of  five  years.  The  endocardium  may  be 
involved  in  general  tuberculosis  (Perroud). 

Tuberculous  Meningitis  (Acute  Internal  Hydrocephalus j  Basilar 
Meningitis.) — Occurrence. — Tuberculous  meningitis  has  been  observed 
in  infants  as  early  as  the  third  month  (Steifen).  Barthez  andRilliet 
have  seen  cases  in  infants  five  months  old.  The  frequency  of  tuber- 
culous meningitis  varies  vs^ith  the  locality.  Dennig  places  the  fre- 
quency of  tuberculous  meningitis  among  children  vp'ho  suffer  from 
tuberculous  disease  at  60  per  cent.,  while  Medin  found  this  form  of 
meningitis  in  15  per  cent,  of  tuberculous  children.  It  is  most  fre- 
quent in  the  nursing  period;  Y5  per  cent,  of  all  cases  occur  under 
the  fifth  year.  The  second  year  of  infancy  shows  the  greatest  num- 
ber of  cases  (Steffen).  It  is  more  frequent  among  male  than  female 
children. 

Of  26  of  my  cases  of  tuberculous  meningitis,  substantiated  either 
by  autopsy  or  by  the  presence  of  tubercle  bacilli  in  the  fluid  obtained 
by  lumbar  puncture,  46  per  cent.  (12)  were  under  four  years  of  age, 
.53  per  cent,  were  four  years  of  age  or  over;  the  average  age  was  four 
years  and  four  months.  The  oldest  case  was  ten  years,  and  the 
youngest  seven  months. 

Etiology  and  Morbid  Anatomy. — Exposure  to  cold  and  traumatism 
predispose  to  the  affection.  In  many  cases  there  is,  in  addition  to 
the  meningeal  disease,  disseminated  tuberculosis  of  the  lungs,  pleura, 
spleen,  liver,  and  peritoneum.  In  other  cases  the  meninges  are  the 
chief  seat  of  the  disease,  only  a  few  isolated  foci  of  tuberculosis  being 
present  elsewhere,  as  in  the  mesenteric  or  bronchial  lymph-nodes. 
It  is  rare  to  find  the  lesions  confined  to  the  meninges,  and  some  authors 


TUBEBCULOSIS.  433 

deny  the  possibility  of  such  a  condition.  It  is  not  always  possible 
to  determine  the  primary  focus  of  infection. 

The  tubercle  bacilli,  which  are  the  causative  factors,  may  be 
carried  by  the  blood  (hsematogen)  to  the  meninges,  and  there  give 
rise  to  a  more  or  less  extensive  miliary  deposit.  The  original  focus 
is  involved  in  inflammatory  exudate.  The  tissue  of  the  cord  and  the 
nerve-elements  may  be  the  seat  of  degenerative  processes. 

Symptoms. — The  symptoms  of  tuberculous  meningitis  cannot  be 
clearly  classified  according  to  stages.  There  is  an  indefinite  period 
of  premonitory  symptoms  followed  rather  abruptly  by  manifestations 
of  cerebral  irritation,  and  ending  with  a  period  in  which  pressure- 
symptoms  are  pronounced.  As  a  rule,  the  disease  is  slow  of  develop- 
ment, although  cases  occur  in  which  the  rapid  malignant  course  simu- 
lates that  seen  in  rapidly  fatal  cerebrospinal  meningitis  of  the  epi- 
demic type.  The  disease  gives  a  varying  clinical  picture  in  the 
different  periods  of  childhood. 

The  infant  of  from  seven  to  twelve  months  refuses  to  nurse,  has 
a  low  fever,  and  may  have  diarrhoea  alternating  with  obstinate  consti- 
pation. The  illness  of  an  infant  is  often  attributed  to  a  fall  occur- 
ring while  it  is  learning  to  walk.  A  weakness  of  the  extremities  is 
thus  indicated.  The  infant  becomes  indifferent  to  its  surroundings 
and  passes  into  a  somnolent  condition.  Emaciation  is  progressive. 
Vomiting  occurs  once  or  twice  daily,  the  food  being  ejected  from  the 
mouth  after  nursing  without  apparent  effort.  The  vomiting  may  be 
followed  by  a  convulsion,  after  which  the  infant  becomes  unconscious. 
There  may  be  strabismus,  or  rigidity  of  the  extremities,  or  the  ex- 
tremities may  be  in  constant  motion  of  an  automatic  character.  The 
convulsions  may  follow  one  another  without  cessation.  These  symp- 
toms may  set  in  after  a  period  of  one,  two,  or  five  weeks  of  ailing. 
In  other  cases  the  infant  may  have  suffered  from  a  chronic  otorrhcea, 
although  otherwise  in  apparent  health.  Suddenly,  vomiting  followed 
by  a  convulsion  sets  in.  This  convulsion  is  the  forerunner  of  symp- 
toms, such  as  coma,  which  denote  that  the  disease  has  become  estab- 
lished without  having  attracted  the  notice  of  the  parents. 

In  children  of  five  years  of  age  the  symptoms  are  more  marked. 
The  child  may  have  an  attack  of  vomiting  and  diarrhoea  and  appar- 
ently recover ;  after  a  few  weeks,  during  which  there  are  irritability, 
loss  of  appetite,  and  progressive  emaciation,  the  child  no  longer  desires 
to  be  up  and  about,  but  lies  quiet  in  its  crib,  with  its  head  in  a  char- 
acteristic rigid  position.  It  develops  strabismus,  becomes  soporose, 
and  cries  out  at  night.  This  cry  is  sometimes  piercing  in  character, 
and  is  the  cause  of  much  concern  to  the  mother.  When  the  symptoms 
of  cerebral  pressure  are  fully  developed,  the  picture  is  in  the  majority 
of  cases  much  the  same.     The  infant  after  the  first  convulsion  lies  in 

28 


434  TEE    SPECIFIC    INFECTIOUS    DISEASES. 

a  soporose  or  comatose  condition.  The  eyes  are  open  and  there  is  a 
vacant  stare ;  the  sclera  may  be  apparent  above  the  cornea ;  the  fonta- 
nelle  if  still  open  is  tense  and  bulging,  and  there  may  be  horizontal 
nystagmus.  The  infant  cries  if  disturbed,  or  may  be  indifferent  to  its 
surroundings.  The  pupils  may  be  unequal  in  size  and  react  to  light. 
In  one  case  which  I  observed  the  pressure-symptoms  were  extreme. 
The  infant  lay  on  its  back  with  rigid  neck  and  arched  back  (opis- 
thotonos), and  emitted  a  piercing  cry  at  intervals.  At  each  cry  the 
pupils  became  successively  dilated  and  contracted  (hippus).  I  have 
seen  this  phenomenon  in  two  cases  of  tuberculous  meningitis.  Opis- 
thotonos may  be  present,  and  the  retraction  of  the  head  may  relax  at 

Fig.  83. 


Babinski's  reflex.    Tuberculous  meningitis  ;  stage  of  facial  palsies.    Boy  seven  years  of  age. 

intervals,  the  muscles  of  the  back  being  lax.  In  some  cases  there  is 
apparently  no  rigidity  of  the  neck.  As  a  rule  there  are  no  convul- 
sions. As  the  infant  or  child  lies  quietly  in  its  crib  the  inspirations 
during  the  stage  of  cerebral  pressure  may  be  very  irregular  or  may 
be  of  the  Cheyne-Stokes  type.  The  outline  of  the  abdomen  is  at  first 
normal  or  there  may  be  a  slight  retraction  at  the  upper  part.  The 
abdominal  wall  may  be  quite  lax,  so  that  the  coils  of  gut  can  be  made 
out.  If  the  case  is  protracted,  retraction  of  the  abdomen  occurs  in 
the  final  stages  of  the  disease.  This  condition  has  been  described 
as  the  boat-like  abdomen.  It  is  not  diagnostic  of  this  form  of 
meningitis. 


TUBERCULOSIS. 


435 


In  rare  cases  spastic  symptoms 
occur  after  the  initial  convulsion, 
rigidly  flexed  arms;  the  Chvo- 
stek  and  Trousseau  symptoms 
are  present.  In  all  of  these 
cases,  if  the  skin  is  stroked  with 
the  finger  ever  so  lightly,  a  red 
mark  appears  over  the  stroked 
area  (tache  cerebrale).  In  the 
spastic  cases  the  knee-reflexes 
may  he  increased,  but  in  the 
non-spastic  cases  they  are  di- 
minished. It  is  difficult  to  elicit 
Kernig's  symptom  in  spastic 
cases,  because  the  infants  lie 
with  the  knees  flexed.  By 
straightening  the  legs  and  thighs 
it  is  possible  in  the  majority  of 
children  to  obtain  the  symptom. 

The  most  important  symp- 
toms of  the  final  stage  of  tuber- 
culous meningitis,  both  in  in- 
fants and  older  children,  are 
the  localized  facial  palsies.  For 
several  days  or  weeks  preceding 
the  fatal  issue,  one  side  of  the 
face  is  seen  to  be  flatter  than 
the  other.  There  may  be  ptosis 
or  lagophthalmus  of  the  eyelids. 
One  eye  may  be  rotated  inter- 
nally, owing  to  paralysis  of  the 
abducens.  The  extremities  are 
also  paretic.  The  arm  and  leg 
of  one  side  may  be  rigid  or 
flexed,  while  those  of  the  oppo- 
site side  are  lax. 

Irritation  of  the  soles  of  the 
feet  may  give  a  Babinski  reac- 
tion (Fig.  83).  In  some  cases 
this  reaction  is  present  inde- 
pendently of  any  irritation  of 
the  plantar  surface.  Toward 
the  end,  convulsive  twitchings 
appear   in  the  muscles   of  one 


closely  resembling  those  of  tetany 
The  infant  lies  comatose,  with 


436 


THE    SPECIFIC    INFECTIOUS    DISEASES. 


or  the  other  side  of  the  face  or  of  the  extremities.  Death  supervenes 
in  coma  with  convulsions.  The  heart  may  continue  to  beat  for  some 
time  after  the  cessation  of  respiration. 

Children  from  six  to  nine  years  of  age  present  a  more  decided 
clinical  picture  in  the  premonitory  stage.  For  some  weeks  before 
the  onset  of  symptoms  of  irritation  they  complain  of  headaches,  fron- 
tal, sincipital,  or  parietal.  The  jDatient  is  listless,  walks  with  an 
unsteady  gait,  and  has  no  desire  to  study  or  play. 

In  one  case  the  child  had  for  some  time  complained  of  pain  in  the 
left  side  of  the  chest  and  had  lost  weight  steadily.  There  were  mild 
pleurisy  and  signs  of  slight  consolidation  at  the  apex  of  the  left  lung. 
There  was  daily  elevation  of  a  few  degrees  of  temperature  in  the 
evening,  and  a  nornaal  temperature  in  the  morning.  In  this  case, 
although  there  were  distinct  signs  of  pulmonary  involvement  of  a 


Fig. 

85. 

DAY  OF 
rLLNESS 

1 

2 

3 

1 

5 

0 

:7 

8 

9 

10 

11 

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Tuberculous   meningitis,    observed    from    the    outset    of   the   symptoms.     Female   infant, 

fourteen  months  old. 


mild  type,  the  emaciation  was  progressive  and  the  leucocyte  counts 
low  (8000  W.B.C.).  At  night  the  typical  cry  of  tuberculous  menin- 
gitis was  present.  In  the  early  stages  of  the  disease  the  patient  was 
conscious  during  the  day,  but  later  became  listless,  irritable,  and 
slept  or  was  drowsy  during  the  day.  When  questioned,  a  slow,  stupid 
answer  was  given.  The  child  vomited  and  at  times  became  nau- 
seated. The  Kcruig  symptom  ap])earcd.  Right  lagophthalmos  was 
present.  The  pupils  were  uiioqua]  in  size,  the  left  being  dilated. 
The  pulse  at  this  time  varied  from  00  to  100  and  was  compressible. 
Finally,  coma  set  in  with  left  facial  palsy  and  convulsive  twitchings 
of  the  left  side  of  the  face.  This  case  was  for  three  months  under 
constant  observation.     In  other  cases  the  vomiting  is  rapidly  fol- 


TUBERCULOSIS. 


437 


lowed  by  paralytic  symptoms  such  as  ptosis  and  facial  paralysis  on 
the  same  side.  There  are  no  convulsions  and  no  cry,  but  there  is 
rigidity  of  the  neck  and  extremities ;  one  patellar  reflex  may  be 
absent.  The  Kernig  symptom  and  Babinski  reflex  are  present  in 
the  majority  of  cases  in  children. 

The  very  rapid  and  fatal  cases  of  tuberculous  meningitis  have 
been  described  by  Osier  and  Dennig.  In  these  the  patient  is  over- 
whelmed by  the  toxaemia  of  the  disease,  no  marked  tuberculous  lesion 
being  present  in  any  organ  but  the  brain.  A  patient  in  apparently 
good  health  is  suddenly  seized  with  convulsions  followed  by  a  period 

Fig.  86. 


Tuberculous  meningitis  ;  general  miliary  tuberculosis  ;  terminal  stage  ;   coma  and 
paralysis.     Boy,  seven  years  of  age. 


of  unconsciousness.  There  are  muscular  relaxation  and  a  vacant 
stare.  The  convulsions  may  be  repeated  at  intervals  of  a  few  minutes 
or  half  an  hour.  There  then  follow  opisthotonos  and  spasms,  and 
the  abdomen  is  tympanitic.  There  is  neither  vomiting,  tache,  nor 
elevation  of  temperature.  There  are  spastic  contractures  of  the 
extremities  alternating  with  relaxations.  Death  occurs  in  a  convul- 
sive seizure  within  ten  hours. 

Schlessinger  reports  a  case  of  tuberculous  meningitis  in  a  child 
two  and  a  half  years  old,  setting  in  with  convulsions,  followed  by 
hemiplegia  and  aphasia  within  thirty-six  hours.  After  these  pre- 
monitory phenomena  the  ordinary  symptoms  of  the  disease  appeared. 
Such  cases  are  exceedingly  rare. 

The  temperature-curve  in  tuberculous  meningitis  is  not  charac- 


438  TEE    SPECIFIC    INFECTIOUS    DISEASES. 

teristic.  In  some  cases  the  temperature  will  not  rise  more  than  a 
degree  or  two  above  the  normal,  intermitting  to  the  normal  or  nearly 
so.  In  other  cases  it  may  be  normal  for  days,  then  rise  a  degree  or 
more,  rarely  above  103°  "^F.  (39.4°  C),  and  then  fall  again  to  the 
normal.  In  cases  in  which  there  is  a  general  miliary  process  the 
temperature  mounts  to  105°-106°  F.  (40.5°-41.1°  C.)  or  higher 
toward  the  close.  The  fatal  issue  in  other  cases  occurs  with  a  sub- 
normal temperature  (96°  F.,  35.5°  C.)  lasting  for  a  day  or  more 
before  death.  If  the  case  is  a  protracted  one,  the  normal  diurnal 
variations  may  be  reversed — that  is  to  say,  the  highest  temperature 
may  be  reached  in  the  morning  hours  and  the  lowest  toward  evening. 
In  the  majority  of  cases,  however,  the  temperature  is  rarely  higher 
than  103°  F.  (30.4°  C). 

The  pulse  is  increased  at  the  onset,  but  during  the  course  of  the 
disease  becomes  slow  and  may  range  from  60  to  100  or  more  during 
the  twenty-four  hours. 

The  respirations  are  irregular,  and  may  vary  from  18  to  60 
within  the  twenty-four  hours,  even  if  no  pulmonary  lesion  is  present. 

Individual  Symptoms. — Onset. — Of  26  cases  which  I  have  utilized 
for  the  purposes  of  this  article,  the  onset  was  slow  and  insidious  in 
77  per  cent.  The  mother  of  the  child  related  that  the  patient  was 
not  quite  well,  or  complained  of  slight  headache,  and  vomited  from 
time  to  time  before  the  appearance  of  marked  symptoms.  In  those 
cases  which  have  come  under  my  observation  early  in  the  disease,  as 
early  as  the  second  day  after  marked  symptoms  were  observed  by 
the  parents,  there  was  no  history  of  vomiting;  as  a  rule,  the  child 
had  a  slight  elevation  of  temperature,  was  irritable  from  time  to  time, 
refused  to  nurse,  and  on  the  whole  the  mother  observed  a  change  in 
the  general  attitude  of  the  child  toward  herself  and  others.  It  was 
only  in  those  cases  which  had  lasted  at  least  a  week  that  there  was  a 
history  of  vomiting.  It  was  only  in  exceptional  cases  that  the 
mother  asserted  the  disease  began  suddenly  with  vomiting  and 
convulsions. 

Vomiting.- — Vomiting  sets  in,  on  the  average,  eighteen  days 
before  the  fatal  issue,  and  may  occur  once  or  twice  daily.  It  may  be 
absent  in  some  cases.  "With  the  vomiting  there  may  be  localized  con- 
vulsions, which  appear  with  the  vomiting,  as  has  been  stated  in 
exceptional  cases  in  which  the  onset  is  sudden,  or  may  appear  two 
weeks  after  the  initial  vomiting  attack. 

Rigidity. — There  are  some  cases  of  tuberculous  meningitis  in 
which  rigidity  of  the  neck  is  absent  throughout  the  disease.  In  only 
one  of  my  cases  was  there  opisthotonos ;  and  the  rigidity,  if  present, 
as  a  rule,  was  but  slightly  marked  ;  that  is,  the  head  was  movable 
almost  to  a  normal  degree.     The  rigidity  is  tested  simply  as  the  child 


> 
w 

X 
X 

< 


TUBEECULOSIS,  439 

lies  in  bed;  the  head  is  raised,  or  an  attempt  made  to  draw  the  chin 
toward  the  sternum  and  note  the  resistance.  In  only  25  per  cent, 
of  the  cases  was  there  palpable  rigidity  or  stiffness  of  the  neck,  and 
this  appeared  late  in  the  course  of  the  disease. 

HypercBsthesia. — Hyperaesthesia,  either  of  the  surface  or  of  the 
senses,  is  absent,  as  a  rule,  in  tuberculous  meningitis;  that  is,  the 
child  reacts  feebly  or  not  at  all  to  irritation,  and,  when  roused, 
momentarily  protests  and  then  falls  into  sopor  again.  In  90  per  cent. 
of  the  cases  there  was  an  absence  of  hypersesthesia  either  of  the  sur- 
face or  of  the  senses;  and  in  this  respect  tuberculous  meningitis  is 
quite  the  opposite  of  cerebrospinal  forms  of  purulent  meningitis  of 
the  epidemic  type,  in  which  hypersesthesia  is  the  rule  and  forms  part 
of  the  general  symptomatology  of  the  disease, 

Kernig  Symptom. — This  symptom  is  present  in  only  50  per  cent, 
of  the  cases.  Its  presence  or  absence  does  not  materially  aid  in  the 
diagnosis. 

Babinski  Reflex.- — In  children  over  two  years  of  age  the  Babinski 
reflex  is  a  valuable  guide  clinically  as  to  the  nature  of  a  menin- 
gitis, if  meningeal  symptoms  are  present ;  more  so  than  the  Kernig 
symptom. 

Of  26  cases  of  tuberculous  meningitis,  the  Babinski  reflex  was 
present  in  15.  It  is  found  exceptionally  in  the  cerebrospinal  menin- 
gitis of  the  epidemic  type,  or  the  suppurative  forms  of  meningitis. 

The  general  reflexes  are  present  in  tuberculous  meningitis  early 
in  the  disease ;  whereas  late  in  the  disease,  when  paralysis  supervenes, 
they  are  absent. 

Pulse. — The  irregularity  of  the  ]3ulse  is  of  no  special  diagnostic 
value  in  tuberculous  meningitis,  and  if  present  is  only  incidental. 
The  irregularity  of  the  pulse  is  quite  a  feature  in  other  forms  of 
meningitis,  especially  of  the  cerebrospinal  type.  In  these  cases  the 
pulse  at  one  moment  may  be  85,  and  immediately  after  may  suddenly 
mount  to  120  beats  a  minute.  In  tuberculous  meningitis,  however, 
the  pulse,  as  a  rule,  is  slower  than  that  of  meningitis  of  the  cerebro- 
spinal type. 

Respiration. — The  respiration  is  irregular  in  most  forms  of  men- 
ingeal trouble  in  children.  In  the  tuberculous  form  of  meningitis, 
after  the  disease  is  well  inaugurated,  the  respirations  are  irregular 
and  shallow,  and  in  a  few  cases,  where  cerebral  pressure  is  very 
marked  late  in  the  disease,  the  respirations  may  assume  the  so-called 
Cheyne-Stokes  rhythm.  The  irregularity  of  respiration  or  pulse  is 
scarcely  an  aid  as  to  differential  diagnosis  of  the  form  of  meningitis 
present. 

Temperaiure. — Of  greater  utility  in  the  diagnosis  is  an  exact 
observation  of  the  course  of  the  temperature.     Although  there  are 


440  TKE    SPECIFIC    INFECTIOUS    DISEASES. 

cases  of  tiiberculoiis  meningitis  in  Avhich  the  temperature  ranges  as 
high  as  104°  to  105°  F.,  this  high  temperature  is  present  only  in 
the  presence  of  complications  of  the  lung,  or  at  a  late  period  of  the 
disease,  toward  the  fatal  issue.  In  most  eases  of  tuberculous  menin- 
gitis which  I  have  seen,  a  low  range  of  temperature  has  been  the  rule. 

Blood. — In  all  my  cases  of  tuberculous  meningitis  I  have  had  the 
blood  examined  at  intervals  of  three  days ;  in  two-thirds  of  the  cases 
there  was  a  leucocyte  count  ranging  below  20,000  to  the  cubic  milli- 
metre. In  the  remainder  of  the  cases,  however,  I  obtained  a  leucocyte 
count  ranging  from  20,000  to  25,000  to  the  cubic  millimetre.  In 
some  cases  there  was  at  some  period  of  the  disease  a  so-called  leuco- 
penia.  In  no  case  except  one,  in  which  the  leucocytes  just  before  the 
fatal  issue  mounted  to  32,000  to  the  cubic  millimetre,  did  the  leuco- 
cyte count  exceed  25,000  to  the  cubic  millimetre;  therefore  a  leuco- 
penia,  however  presumptive  evidence  in  the  face  of  other  symptoms 
of  the  tuberculous  form  of  meningitis,  is  certainly  not  a  positive  evi- 
dence of  the  presence  of  the  disease.  The  lowest  count  in  my  cases 
was  5000  leucocytes  to  the  cubic  millimetre. 

Eyes. — The  condition  of  the  fundus  of  the  eyes  is  of  special 
interest  in  this  form  of  meningitis,  as  compared  with  the  condition  of 
the  disk  and  retina  in  other  types,  such  as  the  cerebrospinal  form  of 
meningitis.  In  20  consecutive  cases  of  tuberculous  meningitis  exam- 
ined by  the  expert  ophthalmologist  in  my  hospital  service,  the  fundus 
was  normal  at  an  early  or  late  period  of  the  disease  in  25  per  cent, 
of  the  cases.  In  75  per  cent,  of  the  cases,  however,  there  was  some 
change  in  the  disk  (optic  neuritis),  or  there  were  present  also  tuber- 
cles in  the  choroid.  In  some  cases  the  disk  was  simply  swollen,  and 
indistinct  at  the  margin ;  in  other  cases  the  veins  were  congested. 
Tubercle  was  found  in  the  choroid  in  6  of  the  20  cases  examined. 
Choroid  tubercle  was  seen  as  early  as  the  first  and  as  late  as  the  sixth 
week  of  the  disease. 

The  cerebral  cry  present  at  night  is  not  distinctive  of  this  form 
of  meningitis;  the  emaciation,  the  retraction  of  the  abdomen,  the 
bulging  of  the  fontanelle  may  be  present  in  other  forms  of  menin- 
gitis, especially  in  that  form  described  by  English  authors  as  the 
posterior-basic  form.  Of  great  service  in  making  a  clinical  diagnosis 
in  this  disease  is  the  presence  of  palsies  of  the  cranial  nerves,  facial 
paralysis;  ptosis,  strabismus,  paralysis  of  the  internal  rectus  of  one 
side,  or  ptosis  of  one  side  with  or  without  lagophthalmos  of  the  oppo- 
site side,  are  indicative  of  a  lesion  at  the  base  of  the  brain.  These 
palsies  are  seen  more  frequently  in  the  tuberculous  forms  of  menin- 
gitis than  in  the  epidemic  cerebrospinal  type  of  meningitis.  I  have, 
however,  seen  these  palsies  in  cases  of  cerebrospinal  meningitis  either 


TUBEBCULOSIS.  441 

in  infants  or  children,  and  in  these  cases  the  palsies  appeared  early 
in  the  disease  rather  than  late,  as  in  the  tuberculous  form. 

Maceivens  Sign. — This  sign  is  elicited  by  percussion  along  the 
parietal  or  frontal  bone  over  the  situation  of  the  anterior  horn  of  the 
ventricles,  and  in  infants  and  children  below  two  years  of  age  is  of 
very  little  value  as  to  the  diagnosis  of  tuberculous  meningitis  with 
consequent  accumulation  of  fluid  in  the  ventricle  as  a  result  of  this 
disease,  inasmuch  as  in  certain  children  suffering  from  pronounced 
rachitis  with  slight  accumulation  of  fluid  in  the  ventricles,  so-called 
hydrocephalus,  this  tympanitic  note  of  Macewen  may  be  obtained. 
The  Macewen  tympanitic  note  is  therefore  of  value  only  in  children 
above  two  years  of  age,  and  must  always  be  sought  by  sitting  the 
patient  upright  in  bed,  inclining  the  head  toward  one  or  the  other 
shoulder,  and  percussing  the  inferior  side  of  the  skull  over  the  parietal 
or  frontal  bone.  When  carried  out  in  this  manner,  a  marked  tympa- 
nitic note  over  the  anterior  horn  of  the  ventricle  is  presumptive  evi- 
dence of  fluid  in  the  same  as  a  result  of  inflammatory  processes  at  the 
base  of  the  brain  and  obstruction  of  the  veins  of  Galen. 

Lwmhar  Puncture. — Lumbar  puncture  is  to-day  the  most  valuable 
aid  we  possess  in  making  a  positive  diagnosis  of  the  various  forms 
of  meningitis.  In  tuberculous  meningitis  there  has  been  discussion 
as  to  the  value  of  an  examination  of  the  puncture  fluid  in  the  diag- 
nosis. First,  as  to  the  cyto  diagnosis,  it  may  be  said  that  in  15  of 
my  cases  of  tuberculous  meningitis  studied  with  a  view  of  noting  the 
character  of  the  cell  elements  in  the  puncture  fluid,  14  showed  a  pre- 
dominance of  mononuclear  cells.  In  1  case  there  was  an  equal  num- 
ber of  mononuclear  and  polynuclear  cells.  It  would  seem,  therefore, 
that  in  tuberculous  meningitis  there  is  a  prevalence  of  mononuclear 
cells,  and  that  this  is  so  constant  that  it  would  appear  to  be  charac- 
teristic. There  are  forms  of  cerebrospinal  meningitis,  however,  espe- 
cially the  chronic  cases,  and  those  of  the  posterior-basic  type  of  long 
duration,  in  which,  instead  of  a  polynuclear  picture  in  the  sediment 
of  the  fluid  obtained  by  lumbar  puncture,  the  mononuclear  picture  is 
apt  to  present  itself,  thus  closely  resembling  what  is  seen  in  tuber- 
culous meningitis. 

The  bacteriology  of  the  fluid  obtained  from  cases  of  tuberculous 
meningitis  by  means  of  lumbar  puncture  has  been  a  matter  of  close 
study  and  difference  of  opinion;  whereas  Lichtheim,  Lenhartz,  and 
Bernheim  found  that  tubercle  bacilli  were  constant  in  the  sediment 
of  the  fluid  obtained  from  these  cases;  Cassell  and  Marfan  have 
asserted  that  their  presence  is  only  occasional.  Of  late  we  have 
examined  the  puncture  fluid  of  14  consecutive  cases  of  tuberculous 
meningitis,  which  were  clinically  diagnosed  as  tuberculous  in  char- 
acter before  the  puncture.      In   13   of  these  cases  tubercle  bacilli 


442  THE    SPECIFIC    INFECTIOUS    DISEASES. 

were  found  bv  Bernstein  of  the  hospital  laboratory.  The  fluids 
were  carefully  centrifuged,  and  the  search  was  exceedingly  pains- 
taking. In  some  cases,  especially  of  children  coming  under  obser- 
vation late  in  the  disease,  tubercle  bacilli  were  not  found  during 
life  in  the  puncture  fluid,  but  were  found  postmortem.  This  is 
explained  by  the  fact  that  in  these  cases  the  tubercle  bacilli  were 
present  in  but  few  numbers  which  during  life  were  kept  evenly  dis- 
tributed throughout  the  subarachnoid  space,  and  were  found  in  the 
puncture  fluid  only  after  prolonged  search.  I  am  inclined  to  believe 
that  the  search  for  tubercle  bacilli  in  the  puncture  fluid  obtained  from 
cases  of  tuberculous  meningitis  is  the  most  positive  and  valuable  aid 
to  the  diagnosis,  and  the  bacilli  can  be  found  in  the  majority  of  cases, 
if  carefully  looked  for. 

Tuberculin  Test. — Finally  the  cutaneous  tuberculin  test  is  of 
great  value  in  the  early  stages  of  the  disease  in  arriving  at  a  diagnosis. 

Differential  Diagnosis. — Tuberculous  meningitis  must  be  differen- 
tiated from  epidemic  cerebrospinal  meningitis  or  sporadic  cerebro- 
spinal meningitis,  suppurative  forms  of  meningitis,  posterior-basic 
meningitis,  polioencephalitis,  apex  pneumonia,  typhoid  fever,  sepsis, 
disturbances  of  the  stomach  and  gut,  ursemia,  helminthiasis,  and 
finally  the  various  forms  of  otitis.  From  cerebrospinal  meningitis 
it  can  be  differentiated  by  the  slow  onset,  by  the  absence  of  opistho- 
tonos, and  in  the  majority  of  cases  a  slight  rigidity  of  the  neck,  by 
the  absence  of  hypersesthesia,  the  presence  of  changes  in  the  fundus 
of  the  eye,  other  optic  neuritis  or  the  presence  of  choroid  tubercle, 
which  will  be  absent  in  cases  of  cerebrospinal  meningitis  and  posterior- 
basic  meningitis,  by  the  low  range  of  the  temperature,  by  the  absence 
of  a  leucocytosis  above  25,000  to  the  cubic  millimetre,  and  finally  by 
the  results  of  an  examination  of  the  fluid  obtained  by  lumbar  puncture. 

Pneumonia  with  cerebral  symptoms  may  simulate  tuberculous 
meningitis.  Here  again  the  history  and  the  character  of  the  delirium 
in  older  patients  will  aid  us.  The  signs  in  the  lung  and  the  presence 
of  leucocytosis,  which  is  marked  in  pneumonia  and  generally  absent 
in  tuberculous  disease,  are  significant.  In  the  majority  of  cases  of 
typhoid  fever  the  history  will  be  of  service  in  connection  with  the 
roseola,  the  Widal  reaction,  the  enlarged  spleen,  and  the  absence  of 
leucocytosis.     Diarrhoea  may  be  present  in  typhoid. 

Disturbances  of  the  gut,  ursemia,  and  helminthiasis  may  present 
symptoms  resembling  those  of  tuberculous  meningitis,  but  the  symp- 
toms in  time  retrograde  or  are  cleared  up  by  a  study  of  the  case. 

I  have  seen  otitis  media  in  nurslings  with  very  limited  areas  of 
bronchopneumonia,  simulate  tuberculous  meningitis.  In  these  cases 
the  infants  may  have  been  ill  for  two  weeks  or  more.  They  start  from 
sleep,  are  irritable  on  awakening,  and  lose  appetite. 


TUBEBCULOSIS.  443 

In  one  case  the  ocular  symptoms  closely  simulated  those  of  tuber- 
culous meningitis.  As  a  rule  there  are  intervals  during  which  the 
child  is  not  only  free  from  pain,  but  also  has  a  normal  temperature. 
At  other  times  the  temperature  has  a  septic  intermittent  character, 
and  mounts  higher  (104°  F.,  40°  C.)  than  in  tuberculous  meningitis. 
Aural  examination  only  will  remove  doubt. 

Duration. — The  duration  of  the  disease  varies  within  wide  limits ; 
I  have  seen  cases  which  extended  over  three  months.  The  majority 
of  cases  last  from  two  to  three  weeks,  but  cases  lasting  five  weeks  are 
not  unusual.  The  very  rapid  cases  in  which  death  ensued  within 
twenty-four  hours  have  been  mentioned. 

Prognosis. — The  prognosis  is  usually  fatal.  Isolated  cases  of 
recovery  have  been  reported.  Martin  has  recently  collected  some 
twenty  cases  of  undoubted  tuberculous  meningitis  which  recovered 
or  had  periods  of  complete  remission  of  symptoms  extending  over 
years.  In  some  of  these  cases  the  lesion  in  the  meninges  subse- 
quently became  a  focus  of  fresh  infection  which  terminated  fatally. 

Treatment. — The  treatment  is  directed  to  alleviating  the  suffer- 
ings of  the  patient.  Lumbar  puncture  is  not  curative,  and  should 
not  be  repeated  after  the  first  diagnostic  puncture  has  been  per- 
formed. 

Tuberculosis  of  the  Brain  (Solitary  Tubercle  of  the  Brain). — 
In  this  there  may  be  a  single  localized  tuberculous  nodule  or  mass  in 
the  brain,  or  several  such  formations  may  be  present.  Demme  found 
a  growth  of  this  kind  in  an  infant  twenty-three  days  old.  Henoch 
has  published  a  case  in  an  infant  eleven  days  old.  The  majority  of 
cases  occur  between  the  second  and  the  fifth  year. 

Morbid  Anatomy. — Tubercle  bacilli  of  diminished  virulence  and 
limited  number  are  carried  from  the  focus  of  tuberculosis  to  the  brain 
through  the  blood-channels,  and  there  lodged  in  a  terminal  blood- 
vessel, forming  solitary  tuberculous  masses  varying  from  the  size  of 
a  pea  to  that  of  a  hazelnut.  These  are  surrounded  by  a  zone  of 
granulation-tissue.  The  neuroglia  in  the  immediate  vicinity  is  the 
seat  of  proliferation,  and  may  form  a  capsule  around  the  growth. 
Circumscribed  meningitis  over  the  situation  of  the  growth,  with  adhe- 
sions of  the  pia  mater  to  the  dura,  may  be  present.  Fully  half  of 
these  solitary  growths  occur  in  the  cerebellum  (Gerhardt).  The 
growth  may  be  single  or  there  may  be  one  large  growth  and  several 
of  smaller  size.  Starr  and  Seidl  found  a  solitary  growth  in  Y7  per 
cent,  of  the  cases.  The  larger  number  of  brain  tumors  in  infancy 
and  children  are  tuberculous.  Starr  found  this  variety  in  152  out 
of  300  cases  of  all  kinds  of  tumors. 

The  symptoms  are  those  common  to  all  tumors,  and  will  be  de- 
scribed in  the  section  devoted  to  Brain  Tumors. 


444  TRE    SPECIFIC    INFECTIOUS    DISEASES. 

SYPHILIS. 

Acquired  Syphilis  of  Infancy  and  Childhood. — Definition. — Syph- 
ilis is  an  infectious  disease  caused  by  the  Spirochseta  pallida  of 
Schaudinn  and  Hoffman,  The  spirochsetse  are  found  in  the  blood 
and  luetic  lesions. 

Mode  of  Infection. — Of  42  cases  of  acquired  syphilis  collected  by 
Fournier,  19  were  infected  by  the  father  or  mother  after  birth,  and 
8  by  the  nurse.  ISTo  case  was  infected  in  passing  through  the  mater- 
nal parts,  and  no  infant  was  infected  by  the  mother  if  she  had 
contracted  the  disease  prior  to  her  accouchement.  A  child  of  a  syphi- 
litic mother,  if  born  free  from  signs  of  syphilis,  cannot  contract  a 
primary  lesion  at  birth  from  the  maternal  parts,  even  if  these  parts 
are  the  seat  of  condylomata,  nor  can  such  an  infant  be  infected  sub- 
sequent to  birth.     It  has  an  acquired  immunity  against  the  disease. 

A  chancre  or  primary  lesion  is,  in  the  infant  as  in  the  adult,  the 
only  evidence  of  acquired  syphilis.  It  is  the  result  of  infection,  and 
must  be  present  in  order  that  the  diagnosis  may  be  certain.  Chancres 
are  rarely  genital.  They  are  found,  as  a  rule,  in  the  mouth,  on  the 
face,  and  on  the  abdomen  and  perineum.  An  infant  may  be  infected 
by  the  nipple  of  the  nurse's  breast.  The  act  of  kissing,  contaminated 
nipples  of  the  nursing-bottle,  instruments,  sponges,  ritual  circum- 
cision, and  humanized  vaccine  virus,  are  all  means  of  infecting  the 
infant.  Since  humanized  vaccine  virus  is  no  longer  used,  this  mode 
of  infection  has  been  eliminated. 

Symptoms.- — The  symptoms  consist  of  a  chancre  or  initial  lesion, 
rarely  genital,  which  appears  three  or  four  weeks  after  inoculation. 
The  other  accidents,  such  as  bubo  or  adenopathies,  the  eruption,  and 
all  the  secondary  symptoms  of  acquired  syphilis,  appear  in  due  course 
as  in  the  adult.  The  genital  chancre  is  seen  in  infections  caused  by 
ritual  circumcision. 

Prognosis. — The  prognosis  as  to  life  is  good  in  comparison  with  that 
in  the  hereditary  form  of  the  disease.  While  in  the  hereditary  form 
the  mortality  is  from  70  to  80  per  cent.,  that  in  the  acquired  form 
is  very  low.  Fournier  lost  only  1  in  42  cases  of  acquired  syphilis. 
The  course  in  infants  and  children  is  benign.  The  chancre  is  not 
well  developed ;  the  induration  is  present  only  a  short  time,  or  may 
even  escape  notice.  The  infants  enjoy  good  health  in  spite  of  the 
presence  of  the  secondary  symptoms.  I  have  confirmed  these  state- 
ments by  observing  7  cases  of  genital  chancre.  The  tertiary  mani- 
festations, such  as  gummata,  bone  lesions,  joint-affections,  eye  and 
laryngeal  symptoms,  and  cerebrospinal  lesions,  appear  from  five  to 
twenty-five  years  after  the  initial  lesion. 

Differential  Diagnosis. — Acquired  syphilis  must  be  differentiated 


SYPHILIS.  445 

from  the  hereditary  form  of  the  disease.  Hereditary  or  congenital 
syphilis  appears  early  without  an  initial  lesion,  showing  general  sec- 
ondary symptoms  from  four  to  six  weeks  after  birth.  The  chancre 
is  the  first  manifestation  in  acquired  syphilis.  In  Fournier's  42 
cases  the  chancre  appeared  during  the  first  year  of  life  in  19,  and 
during  the  second  year  in  10  cases.  The  snuffles,  pemphigus,  and 
pseudoparalysis  are  not  present  in  acquired  syphilis.  Secondary 
accidents,  such  as  mucous  patches  or  papules  about  the  genitals, 
appearing  during  later  childhood  are  probably  traceable  to  a  post- 
natal infection.  Interstitial  keratitis,  bone  syphilis,  and  cutaneous 
stigmata  are  common  to  the  hereditary  and  acquired  forms  of  the 
disease.  It  is  sometimes  very  difficult  to  decide  which  form  of  the 
disease  is  present.  Thus  far  no  one  has  shown  conclusively  that 
Hutchinson's  teeth  are  present  in  acquired  forms  of  syphilis  in  in- 
fancy and  childhood.  Their  presence  is  therefore  strong  presumptive 
evidence  of  hereditary  syphilis. 

Late  Hereditary  Syphilis  (Syphilis  Hereditaria  Tarda). — • 
Definition. — Fournier  defines  late  hereditary  syphilis  as  a  symptom- 
complex  of  accidents  of  syphilis  originating  in  a  hereditary  infection, 
which  manifests  itself  at  a  more  or  less  advanced  period  of  life,  that 
is  to  say,  in  the  majority  of  cases  between  the  third  and  the  twenty- 
eighth  year. 

Classification. — There  are  two  classes  of  cases.  In  the  first,  the 
patient  has  remained  in  perfect  health  without  any  of  the  eruptive 
or  other  symptoms  of  hereditary  syphilis  until  at  an  advanced  period 
of  childhood  one  or  more  of  the  symptoms  of  late  hereditary  syphilis 
are  developed.  In  the  second,  the  late  symptoms  have  been  preceded 
by  the  early  symptoms  of  hereditary  syphilis.  The  late  symptoms 
may  develop  after  an  interval  of  from  ten  to  fifteen  years.  The  cases 
of  the  former  class  have  been  the  subject  of  much  discussion.  The 
occurrence  of  the  second  class  of  cases  is  now  well  established ;  it  is 
often  very  difficult  to  determine  the  hereditary  or  acquired  nature  of 
the  original  infection. 

Symptoms. — Fournier,  in  classifying  the  symptoms  of  212  cases 
of  late  hereditary  syphilis,  found  the  eye  to  be  the  organ  most  fre- 
quently affected,  ^ext  in  order  of  frequency  are  the  lesions  of  the 
bones  and  skin.  The  rarer  affections  are  those  of  the  kidney,  larynx, 
spinal  cord,  testes,  and  lungs. 

The  subjects  of  late  hereditary  syphilis  have  certain  well-defined 
general  characteristics.  They  are  constitutionally  delicate  and  have 
an  emaciated  habitus.  The  skin  presents  a  grayish  ansemia.  There 
is  an  arrest  in  the  development  of  bone  and  musculature.  The  men 
are  undersized  and  present  the  picture  which  has  been  characterized 
as  infantilism.     The  sigTis  of  virility,  such  as  the  beard,  hair  under 


446 


TEE    SPECIFIC    INFECTIOUS    DISEASES. 


the  arm  and  on  the  pubes,  are  scantily  developed.  The  testes  are 
rudimentary.  The  adult  has  the  appearance  of  a  boy  of  fourteen 
or  fifteen  years.  The  women  are  correspondingly  backward  in  devel- 
opment. 

The  Eye. — The  eye  symptoms  appear  most  frequently  at  the  age 
of  ten  or  fifteen  years,  but  may  become  evident  as  early  as  the  third 
year.  The  principal  symptom  is  a  keratitis  of  the  diffuse  intersti- 
tial variety,  the  so-called  keratitis  of  Hutchinson.  The  cornea  has  a 
slightly  cloudy  or  filmy  appearance,  or  the  whole  structure  is  diffusely 


Fig. 

87. 

l 

I 
1 

s 

/ 

1 

•  i 

mm 

/ 

■  ^.   K 

--^ 

1^ 

J 

Late  hereditary  syphilis  ;  bone  deformity  and  sinus.     Child,  three  years  of  age. 

opaque.  The  other  ocular  accidents  are  plastic  iritis,  which  fixes  the 
iris,  thus  limiting  its  action  and  causing  a  difference  in  the  size  of  the 
pupils.     The  rarest  manifestations  are  miliary  gummata  of  the  iris. 

Bone-lesions.- — -The  bone-lesions  are  most  frequent  between  the 
fifth  and  the  twelfth  year. 

The  head  presents  a  cuboidal  shape ;  the  forehead  is  prominent ; 
the  frontal  bones  have  large  bosses,  as  have  also  the  parietal  bones. 
The  longitudinal  suture  is  depressed,  giving  a  natiform  shape  to  the 
head.  The  cranium  may  have  the  form  seen  in  mild  degrees  of 
hydrocephalus. 

The  nose,  on  account  of  the  destruction  of  the  bony  septum,  has 
a  depressed  bridge.  The  bony  and  cartilaginous  septa  form  an  acute 
angle,  and  a  peculiar  retrousse  appearance  is  given  to  the  organ. 


SYPHILIS.  447 

Both  bony  and  cartilaginous  septa  may  be  destroyed.  The  whole 
organ  is  flattened,  the  tip  of  the  nose  being  wrinkled  into  three  or 
more  folds. 

The  long  bones  are  especially  affected  by  the  accidents  of  late 
hereditary  syphilis,  the  tibia  being  most  frequently  affected.  The 
lesion  may  consist  in  an  osteoperiostitis,  a  gummatous  osteoperiostitis, 
or  a  gummatous  osteomyelitis. 

If  osteoperiostitis  is  present,  there  are  diffuse  swelling  and  thick- 
ening of  the  bone — the  so-called  sabre-like  deformity  (Fig.  87). 
This  process  may  affect  the  long  bones  of  the  upper  extremities.  The 
gummatous  lesions  of  osteoperiostitis  form  numerous  irregular  pain- 
ful swellings  on  the  bone.  Gummata  are  present  on  the  flat  bones  of 
the  cranium.  When  these  break  down,  the  destructive  processes  may 
expose  the  dura  mater.  Arthropathies  with  synovitis  may  be  mis- 
taken for  tuberculosis  of  the  joint.      This  form  of  synovitis  is  gener- 

FiG.  88. 


Radius  affected  with  osteoperiostitis  due  to  late  syphilis. 

ally  bilateral.  One  of  my  cases,  a  child  five  years  of  age,  gave  no 
history  of  syphilis.  The  radius  on  both  sides  was  affected  by  osteo- 
periostitis (Fig.  88).  The  joints  may  be  deformed  by  osteophytic 
growths  involving  the  epiphysis  or  head  of  the  bone. 

Ear. — The  ear  is  affected  by  an  otitis  with  destruction  of  the 
ossicles,  and  even  by  mastoid  disease.  In  other  cases  deafness  super- 
venes without  premonitory  symptoms. 

SMn  and  Mucous  Membranes. — The  skin  and  mucous  membranes 
show  certain  stigmata  in  the  form  of  cicatrices  of  recent  or  old  ulcera- 
tions. These  may  exist  on  any  part  of  the  body,  but  are  especially 
characteristic  on  the  vermilion  border  of  the  lips  and  at  the  corners 
of  the  mouth,  where  they  are  seen  as  radiating,  linear  pale-white 
fissures. 

Lymph-nodes. — The   lymph-nodes   may   be   enlarged,    especially 


448  TRE    SPECIFIC    INFECTIOUS    DISEASES. 

those  on  each  side  of  the  neck,  below  the  jaw,  and  in  the  axilla  and 
inguinal  regions. 

Spleen. — The  spleen  is  enlarged,  but  not  so  frequently  as  is  stated 
by  some  authors.     Fournier  found  it  enlarged  in  15  out  of  212  eases. 

Liver. — The  liver  was  enlarged  in  25  cases.  In  one  of  my  cases 
of  late  hereditary  syphilis  in  a  child  eight  years  of  age,  postmortem 
examination  revealed  cirrhosis  of  the  liver  of  the  hypertrophic  type. 
There  were  enlargement  of  the  spleen,  icterus,  and  ascites ;  Hutchin- 
son's teeth  were  well  marked,  and  there  were  also  adenopathies  and 
changes  in  the  bloodvessels. 

Mental  and  Other  Symptoms. — Fournier  among  others  has  de- 
scribed forms  of  idiocy  and  epilepsy  of  syphilitic  origin,  but  there  is 
great  difference  of  opinion  on  this  question.  The  theory  of  Parrot, 
that  rachitis  is  the  result  of  syphilis,  is  now  generally  abandoned. 
The  deformities  of  the  teeth  which  occur  in  late  hereditary  syphilis 
will  be  found  fully  described  in  the  section  devoted  to  Dentition. 

Congenital  or  Hereditary  Syphilis. — Etiology.— Congenital  or 
hereditary  syphilis  results  from  the  infection  of  the  ovule  or  foetus 
in  utero.  This  may  occur  in  a  number  of  ways,  but  in  the  great 
majority  of  instances  it  results  from  infection  of  the  foetus  through 
the  father.  The  more  recent  the  syphilis  of  the  father,  the  more 
likely  is  the  infection  to  occur.  It  is  most  certain  to  occur  if  both 
the  father  and  mother  suffer  from  recent  syphilis  at  the  time  of  con- 
ception. The  father  may  at  the  time  of  insemination  suffer  from 
recent  syphilis  and  the  mother  be  healthy.  Under  such  conditions 
the  child  is  born  syphilitic.  The  mother  may  not  show  any  signs  of 
active  syphilis  either  during  pregnancy  or  at  any  subsequent  period. 
The  mother  may  suckle  her  offspring,  which  shows  all  the  marks  of 
active  hereditary  syphilis,  without  becoming  infected,  but  the  child 
will  infect  any  strange  nurse.  The  mother  has  during  pregnancy 
acquired  an  immunity  against  the  infection.  This  phenomenon, 
which  is  a  matter  of  daily  observation,  was  first  brought  to  the  notice 
of  the  profession  by  the  distinguished  surgeon  Colles,  and  has  since 
become  known  as  Colles's  law.  The  longer  the  mother  is  subjected 
to  the  influence  of  the  syphilitic  virus,  the  more  permanent  does  her 
immunity  become.  Thus  a  mother  who  has  at  first  miscarried  may 
eventually  give  birth  to  a  living  infant  which  bears  the  marks  of 
syphilis.  As  the  virus  becomes  weakened,  the  mother  may  bear  an 
infant  to  all  appearances  healthy.  In  the  interval,  although  repeat- 
edly pregnant,  the  mother  has  shown  no  signs  of  active  syphilis. 

If  the  father  is  healthy  at  the  time  of  insemination  and  the 
mother  the  subject  of  recent  syphilis,  the  infant  will  be  born  syphilitic. 
On  the  other  hand,  if  the  mother  contracts  syphilis  after  conception, 
the  father  at  the  time  of  conception  having  been  healthy,  the  infant 


SYPHILIS.  449 

may  or  maj  not  be  born  syphilitic.  The  nearer  the  time  of  the  infec- 
tion of  the  mother  to  the  end  of  her  period  of  pregnancy,  the  more 
likely  is  the  infant  to  escape  (Monti,  Zeissel,  Hutchinson).  Such  an 
infant  if  born  healthy  may  become  infected  in  the  ordinary  way  from 
the  mother  after  birth. 

A  father  who  has  passed  through  the  secondary  manifestations  of 
syphilis  may  in  the  late  secondary  period  or  tertiary  stage  fail  to 
convey  the  poison  in  the  sperma.  The  result  will  be  an  infant  free 
from  syphilis  (Fournier,  ITeuman).  Yet  so  far-reaching  is  the  influ- 
ence of  the  syphilitic  dyscrasia  that  such  an  infant,  although  born 
healthy  and  at  no  time  showing  signs  of  syphilis,  may  present  certain 
signs,  such  as  peculiarities  of  bone  formation  (teeth)  traceable  to  the 
syphilitic  virus  (parasyphilitic). 

Exceptions  to  Colles's  law  occur,  as  is  to  be  expected.  Fournier 
has  recorded  cases  in  which  mothers  apparently  immune  have  devel- 
oped signs  of  secondary  syphilis  after  the  birth  of  the  infant.  Finger 
has  met  cases  in  which  tertiary  syphilis  developed  in  the  mother  sub- 
sequent to  pregTiancy  without  the  occurrence  in  her  of  any  of  the 
signs  of  secondary  syphilis. 

Of  218  mothers  who  had  borne  syphilitic  infants,  Hochsinger 
found  72  who  were  free  from  manifestations  of  secondary  or  tertiary 
syphilis  although  observed  for  years. 

Morbi^  Anatomy. — In  considering  the  pathology  of  hereditary 
syphilis,  Hochsinger  divides  the  cases  into  four  classes : 

The  first  class  of  cases  die  in  utero  before  the  eighth  month. 
Autopsies  upon  such  foetuses  show  general  parenchymatous  involve- 
ment of  the  glandular  apparatus  with  epiphyseal  osteochondritis. 

The  second  class  includes  infants  born  living  or  dead  before  the 
end  of  pregnancy.  They  present  at  birth  a  papulobullous  syphilide. 
In  these  cases  diffuse  parenchymatous  changes  are  found  in  the  vis- 
cera, and  frequently  marked  epiphysitis. 

The  third  class  comprises  infants  born  living  and  without  any 
exanthema,  but  which  later  develop  an  exanthema  independently  of 
visceral  or  bony  changes. 

The  fourth  class  comprises  infants  born  without  an  exanthema, 
but  having  at  birth  marked  visceral  and  bone-changes. 

The  lesions  as  found  in  the  various  parts  of  the  body,  in  detail, 
are  as  follows : 

SJcin. — We  find  that  the  skin  shows  an  increase  in  the  thickness 
of  the  rete  Malpighii,  caused  by  swelling  of  the  cells  of  the  rete,  serous 
infiltration  of  this  layer,  and  an  increase  of  the  spaces  between  the 
cells  of  the  rete.  The  horny  layer  of  the  skin  is  much  thinned  in 
comparison,  although  there  is  a  constant  throwing-off  of  the  cells  of 
this  layer  in  lamellae.     The  epithelium  of  the  sweat-glands  is  swollen 

29 


450  THE    SPECIFIC    INFECTIOUS    DISEASES.  ' 

and  there  is  a  small  round-cell  infiltration  between  the  glands.  There 
is  a  vasculitis  of  the  small  bloodvessels  affecting  the  external  coat 
chiefly.  Pemphigus  and  bullse  result  from  infiltration  of  the  rete 
and  the  lifting  up  and  separation  of  the  horny  from  the  papillary 
layer  by  serum. 

The  Lungs. — The  changes  in  the  lungs  may  be  considered  under 
two  heads : 

First,  the  lungs  of  infants  born  dead  or  who  have  died  soon  after 
birth,  are  collapsed,  devoid  of  air,  hyperasmic,  and  dark  red  in  color. 
In  rare  cases  the  lungs  may  be  diffusely  whitish  yellow  in  color, 
giving  the  appearance  of  the  so-called  pneumonia  alba.  The  second 
class  comprises  infants  that  have  breathed,  and  that  show  a  gray  or 
grayish-white  discoloration  of  the  lungs  in  places.  There  is  residual 
air  in  the  lungs,  and  they  are  denser  and  larger  than  is  normal. 

Ziegler  has  shown  that  the  changes  in  the  lungs  consist  chiefly  in 
an  increase  in  the  interalveolar  connective  tissue,  the  formation  of 
new  vessels,  and  vasculitis  of  the  bloodvessels.  In  the  majority  of 
newly  born  infants  the  alveolar  epithelium  is  but  little  affected.  In 
pneumonia  alba  there  is  a  proliferation  of  the  alveolar  epithelium, 
giving  a  peculiar  appearance  and  color,  hence  the  name. 

The  Liver.- — Changes  in  the  liver  are  quite  constant  in  hereditary 
syphilis.  These  may  or  may  not  be  associated  with  enlargement  of 
the  organ.  Out  of  148  cases  of  congenital  syphilis,  Hochsinger  found 
the  liver  enlarged  in  46  ;  in  all  but  2  the  spleen  also  was  enlarged ;  in 
the  severer  cases  the  liver  was  markedly  enlarged. 

The  pathological  changes  in  the  liver  have  been  described  by 
Hudelo,  Hochsinger,  and  Heller.  There  may  be  simply  diffuse, 
small  round-cell  infiltration  of  the  interstitial  connective  tissue,  with 
inflammatory  changes  in  the  smaller  arteries.  The  liver  in  these 
cases  is  not  enlarged.  In  the  cases  presenting  an  enlarged  liver  there 
is  interacinous  proliferation  of  connective  tissue,  beginning  at  the 
periportal  region  and  following  the  course  of  the  bloodvessels.  Ther^ 
is  vasculitis,  shown  in  a  thickening  of  the  adventitia  of  the  blood- 
vessels. The  parenchyma  is  degenerated.  In  other  cases  interacinous 
collections  of  small  round  cells  are  on  gross  sections  of  the  liver  seen 
as  yellow  pinhead-sized  spots.  These  are  called  by  Hochsinger  miliary 
gummata.  Fully  developed  gummata  of  large  size  are  very  rare  in 
the  liver  of  infants  affected  with  hereditary  syphilis. 

Spleen. — The  spleen  is  in  some  cases  enlarged  to  ten  times  its 
normal  size.  Gummata,  single  or  multiple,  occur,  but  are  rare.  In 
hereditary  syphilis  not  only  is  the  parenchyma  increased,  but  also 
the  connective  tissue  of  the  spleen. 

Kidneys. — In  rare  cases  there  are  indni'ation  and  contraction  of 


PLATE  XXV  r 


Congenital  Syphilis.      Showing  nasal  deformity. 
Newborn  infant. 


SYPHILIS.  451 

the  kidnej.  The  parenchyma  is  retarded  in  development  by  intra- 
uterine syphilis  and  the  connective  tissue  increased. 

Panc7-eas.- — The  pancreas  may  be  enlarged  and  infiltrated,  the 
parenchyma  hard,  and  the  interstitial  connective  tissue  increased. 
There  may  be  condylomatous  ulcerations  on  the  tongue,  pharynx, 
and  tonsil. 

Glandular  Apparatus. — According  to  Hochsinger,  the  glandular 
apparatus  of  the  gut  may  show  a  diffuse  small-cell  infiltration, 
Peyer's  patches  may  be  infiltrated,  and  the  vessels  may  be  the  seat 
of  a  vasculitis.  The  lymph-nodes  are,  as  a  rule,  little  changed  except 
in  cases  with  late  manifestations.  The  thymus  gland  in  cases  of 
hereditary  syphilis  has  been  found  to  be  the  seat  of  cystic  degenera- 
tion (Eberle,  Ribbert),  caused  by  the  dilated  epithelial  spaces  of  the 
foetal  thymus. 

Bone-changes. — The  bone-changes  in  hereditary  syphilis  occur 
principally  at  that  part  of  the  bone  between  the  epiphysis  and 
diaphysis  in  the  lower  end  of  the  femur,  tibia,  and  radius.  In  the 
milder  forms  of  bone-change  there  is,  according  to  Ziegler,  little  real 
inflammation.  There  are  irregularity  in  the  deposit  of  lime  salts 
and  the  formation  of  marrow-spaces.  In  severe  forms  there  is  a  true 
inflammatory  process.  In  the  vicinity  of  the  joint-cartilage,  grayish- 
red,  yellowish-white,  or  yellowish-green  foci  of  osteomyelitis  are 
found.  The  irregular  deposit  of  lime  salts  and  the  formation  of 
marrow-spaces  are  evidenced  by  reddish-yellow  projections  of  marrow- 
spaces  into  the  adjacent  proliferated  cartilage.  These  give  the  epi- 
physeal junction  a  more  irregular  and  widened  appearance  than  is 
normal.  Sometimes  separation  of  the  epiphysis  at  the  junction  of 
the  diaphysis  occurs.  The  above  changes  are  frequent,  although  not 
constant.  In  the  later  stages  of  syphilis  in  children  there  are,  as  in 
the  adult,  caries,  necrosis,  and  gumma  formations  in  the  long  and 
flat  cranial  bones. 

Symptoms. — The  symptomatology  of  hereditary  syphilis  varies 
largely  with  the  class  of  cases.  In  some  cases  the  foetus  is  expelled 
dead,  bearing  the  marks  of  fully  developed  syphilis  in  the  shape  of 
skin,  bone,  and  visceral  lesions.  In  others  the  infant  is  born  living, 
but  presents  a  few  very  characteristic  signs  of  syphilis,  such  as  the 
presence  of  buUse  or  pemphigus  either  on  the  palms  or  on  the  soles  of 
the  feet.  The  vesicles  may  be  filled  with  a  purulent  fluid.  As  a  rule 
these  infants  are  emaciated.  In  some  cases  the  bridge  of  the  nose  is 
sharply  depressed  and  forms  a  distinct  angle  with  the  cartilaginous 
septum  (Plate  XXVI. ).  This  intra-uterine  deformity  in  the  new- 
born infant  has  been  studied  by  Epstein.  Such  infants  sufl^er  from 
a  troublesome  coryza  and  cannot  breathe  freely  through  the  nose. 
They  present  enlargement  of  the  liver  and  spleen,  and  there  may 


452 


TEE    SPECIFIC    INFECTIOUS    DISEASES. 


be  a  few  copper-colored  discolorations  on  the  skin  of  tlie  forehead 
and  nose.  The  lips  have  a  shiny,  glossy  appearance,  and  after  a 
time  may  present  distinct  rhagades.  Some  days  after  birth  there 
is  a  diffuse  syphilitic  eruption  of  papules  or  vesicopapules,  with  the 
so-called  diffuse  induration  of  the  skin  of  the  palms  of  the  hand  and 
soles  of  the  feet,  described  by  Hochsinger.  Here  and  there  discol- 
ored spots  which  were  formerly  mistaken  for  papules  may  be  seen. 
The  skin  of  the  face  may  have  a  diffuse  coppery  color.  Patches  of 
discolored  skin  appear  and  become  confluent,  the  coryza  and  rhagades 

Fig.  89. 


Hereditary  sj-philis  ;  rhagades  and  mueous  patches  of  the  lips. 


along  the  lips  and  at  the  angle  of  the  mouth  become  more  marked,  and 
the  rhagades  bleed  easily. 

In  another  class  of  cases  the  infant  is  born  well  nourished  and  has 
a  good  color.  Within  from  two  to  four  weeks  a  general  eruption  of 
])a])ules  and  vesico-papuh  s  appears.  Some  of  the  vesico-papules  are 
]nirulent,  and  after  bursting  dry  up,  leaving  the  surface  covered  with 
crusts  on  a  copper-colored  base.  In  these  cases  the  manifestations 
on  the  mucous  membranes,  including  coryza,  mucous  patches,  and 
rhagades  are  also  gTadually  developed  (Fig.  81) ).  If  the  above  symp- 
toms are  marked,  we  may  find  enlargement  of  the  liver  and  spleen. 
I  have  seen  the  most  marked  signs  of  h(  rcditary  syjjhilis  of  the  skin 
without  the  slightest  enlargement  of  the  liver  or  spleen.     As  a  rule, 


SYPHILIS. 


453 


the  arms  will  present  papules,  which  may  ulcerate  at  the  points  of 
contact  with  adjacent  surfaces  of  skin.  The  typical  condyloma  lata 
is  not  frequent  in  early  hereditary  syphilis.  The  nates  have  a  cop- 
pery shining  color,  are  cracked  in  places  and  diffusely  indurated 
(Hochsinger's  induration).  The  trunk  may  present  few  symptoms. 
The  bicipital  glands  are  enlarged  if  the  syphilitic  exanthema  is  fully 
developed.  The  thighs  show  brownish,  copper-colored  patches.  These 
patches  give  the  skin  a  marbled  appearance,  which  differs  from  that 
of  the  so-called  healthy  marbled  skin  in  that  the  discolored  areas  are 
surrounded  by  normally  colored  skin,  while  in  ordinary  marbled  skin 
the  opposite  condition  obtains.     On  exposed  areas,  such  as  the  knees, 

Fig.  90. 


Congenital  syphilis  ;  circinate  syphilide  of  the  nose. 


nates,  soles  of  the  feet,  and  palms  of  the  hands,  the  skin  is  diffusely 
indurated. 

In  a  detailed  consideration  of  the  lesions,  those  of  the  skin  are 
the  first  to  engage  attention.  The  most  common  forms  of  eruption 
are  the  papular  or  the  papulopustular  form  of  syphilide.  This  may 
be  combined  with  the  macular  form ;  in  fact,  it  is  common  to  find  in 
the  same  case  all  forms  in  various  stages  of  development. 

The  papules  occur  on  the  forehead,  palmar  surface  of  the  hands 
and  plantar  surface  of  the  feet,  and  on  the  nates  (Fig.  90).  They 
show  a  distinct  induration  of  the  skin,  are  raised  above  the  surface, 
and  have  a  glossy,  copper-colored  appearance.  On  the  nates  or  in  the 
gi'oin  the  papules  may  ulcerate ;  very  rarely  these  form  condylomata 


454  THE    SPECIFIC   INFECTIOUS   DISEASES. 

lata  in  the  early  periods  of  congenital  syphilis.  The  condyloma  is 
a  feature  of  the  later  period  of  this  disease  (Plate  XXVII.).  Ma- 
cules develop  within  the  first  three  months  of  life,  and  from  the  sixth 
to  the  tenth  week  are  associated  with  seborrhoea.  Infants  thus  affected 
are  born  with  a  peculiar  anaemia,  in  which  the  skin  has  a  cadaveric 
hue.  The  macules  appear  on  the  forehead  and  face  as  copper-hued 
spots,  which  increase  in  number  until  the  skin  has  a  general  marbled 
appearance  (roseola  syphilitica).  They  then  fade,  leaving  the  sur- 
face covered  with  brownish-red  areas.  These  persist  around  the  alse 
nasi  and  the  forehead  for  a  long  time,  giving  the  face  a  peculiar  dirty- 
yellow  spotted  appearance. 

The  diffuse  syphilitic  infiltration  of  the  skin  has  been  studied  by 
Hochsinger,  It  is  not  the  forerunner  or  the  sequence  of  any  papular 
eruption.  It  may  be  present  as  in  one  of  my  cases  in  the  first  week 
after  birth,  but  appears  in  the  third  week  in  50  per  cent,  of  the  cases, 
and  reaches  its  height  between  the  eighth  and  the  tenth  week.  It 
first  presents  discolored  areas  on  the  palms  and  on  the  soles  of  the 
feet,  on  the  nates,  the  calves  of  the  legs,  also  on  the  cheeks  and  chin, 
where  it  forms  rose-colored  or  copper-colored  areas  which  coalesce. 
The  soles  and  palms  may  appear  diffusely  red  or  bluish  and  glossy. 
The  skin  is  dift'usely  thickened  on  the  palms  and  soles  and  desqua- 
mates in  lamellae.  At  the  junction  of  the  mucous  membranes  and 
skin  fissures  result  on  account  of  the  thickening  of  the  skin.  The  lips 
appear  anaemic  as  a  result  of  the  infiltration  of  the  mucous  membrane, 
and  are  fissured.  There  are  rhagades  at  the  alae  nasi.  The  rhagades 
at  the  angles  of  the  mouth  are  covered  with  a  bluish-white  pellicle, 
and  the  surrounding  skin  is  copper-colored.  There  are  swelling  of 
the  nasal  mucous  membrane  with  a  thin,  purulent  discharge  mixed 
with  blood.  The  hair  falls  out  on  account  of  the  infiltration  of  the 
scalp;  the  scrotum  is  thickened  and  fissured  from  the  same  cause. 

The  blood  shows  all  stages  of  anaemia,  from  the  mildest  to  the 
grave  pseudoleukaemic  anaemia  of  von  Jaksch,  which  some  authors 
trace  to  syphilitic  influences. 

The  bones  are  affected  with  an  osteochondritis,  already  described. 
This  may  appear  in  the  first  few  weeks  or  at  a  much  later  period.  It 
manifests  itself  l)y  ])(iiii  in  moving  the  joints.  The  infant  cries  when 
handled.  The  mother  notices  that  one  or  the  other  arm  lies  motionless 
at  the  side,  and  that  every  attempt  to  move  it  causes  pain.  Parrot 
described  this  condition  as  a  pseudoparalysis.  At  the  junction  of  the 
epij)hysis  and  diaphysis  at  the  lower  end  of  the  humerus  or  radius  the 
bone  may  be  swollen  and  painful.  As  a  rule,  the  process  affects  the 
upper  extremity  on  one  side  (m]y,  bnt  in  severe  cases  both  the  upper 
and  lower  extremities  may  be  involved.  In  some  cases  this  symptom 
may  be  present  without  a  skin  eruption.     The  other  conditions  which 


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SYPHILIS. 


455 


simulate  it  are  septic  osteomyelitis  involving  the  joints,  scurvy,  and 
severe  rachitis.  I  have  known  instances  in  which  prolonged  obser- 
vation was  necessary  to  clear  up  the  case. 

A  very  characteristic  but  not  common  affection  of  the  bones  is 
the  so-called  dactylitis  syphilitica  (Fig.  91).  This  may  appear  as 
early  as  the  fourth  week,  and  may  be  associated  with  swelling  of  the 
epiphyses  of  the  long  bones.  It  consists  of  a  fusiform  swelling  of 
the  phalanges  of  one  or  more  fingers.  According  to  Taylor,  this  is 
primarily  a  gummatous  infiltration  of  the  skin,  the  periosteum,  bone, 
and  epiphyseal  cartilage.     In  another  form  the  periosteum  and  the 

Fig.  91. 


Congenital   syphilis ;    onychia  of  all   the  nails ;   dactylitis    of  the   phalanx  of  the   index 
finger.     Infant,  four  months  of  age. 


bone  itself  are  the  seat  of  the  gummatous  inflammation,  the  epiphysis 
and  the  joint  becoming  involved  later  in  the  process.  In  neglected 
cases,  fistulee  and  destruction  of  the  joint  may  result  from  necrosis 
of  the  epiphysis.  The  diagnosis  of  these  forms  of  dactylitis  from 
tuberculous  spina  ventosa  is  sometimes  difficult,  and  often  impossible 
without  mercurial  treatment.  Cases  of  rachitis  which  involve  the 
phalanges  of  all  the  fingers  simulate  very  closely  the  above  affection 
(see  Rachitis). 

Syphilitic   affection  of  the  liver  gives  no   symptoms.     Henoch 
records  cases  in  which  icterus  was  associated  with  enlaro;ement  of 


456 


THE    SPECIFIC    INFECTIOUS    DISEASES. 


the  organ.  Hochsinger  denies  the  occurrence  during  the  nursing 
period  of  any  authentic  case  of  syphilis  of  the  liver  with  icterus 
or  ascites. 

Sonima,  Fischl,  and  Kohts  have  described  symptoms  of  cerebral 
syphilis  in  infants  that  were  subjects  of  hereditary  syphilis.  Con- 
vulsions, hydrocephalus,  epilepsy,  and  paralyses  have  been  traced  to 
the  presence  of  gummous  meningitis  or  sclerosis.  That  such  changes 
occur  as  a  direct  result  of  syphilis  at  so  early  a  period  is  doubted  by 
Henoch.  I  have  not  seen  manifestations  of  cerebral  syphilis  in  in- 
fants. Henoch  is  also  inclined  to  include  Mracek's  cases  of  hemor- 
rhagic syphilis  among  the  septic  diseases  of  the  newborn  occurring  in 
syphilitic  infants. 

Antonelli  in  1897  described  changes  in  the  fundus  oculi  of  new- 
born syphilitic  infants.     These  consisted  of  optic  neuritis,  retinitis 

Fig.  92. 


Hereditary  syphilis  ;  gummata  of  the  cranial  bones.     Child,  eighteen  months  of  age. 

vascularis,  and  retinochoroiditis.  He  believes  these  changes  to  be 
causative  in  the  production  of  myopia  and  strabismus  in  such  infants. 

Diagnosis. — The  diagnosis  of  hereditary  syphilis  is  not  difficult  in 
the  vast  majority  of  cases.  If  the  fcetus  is  expelled  dead  it  bears  the 
marks  of  syphilitic  infection,  such  as  bullae  and  affections  of  the 
internal  organs.  Maceration  alone  is  not  indicative  of  syphilis.  If 
the  infant  is  born  living,  the  evidences  of  syphilis  are  sometimes  very 
few  and  equivocal. 

After  a  few  months  the  diagnosis  will  sometimes  be  difficult ;  the 
eruption  will  have  disappeared,  leaving  only  an  anaemia  of  uncertain 
origin,  with  a  few  discolored  areas  about  the  nasolabial  folds  and 
around  the  temporal  region.     There  is   a   suspicious   dirty-looking 


SYPHILIS.  457 

seborrhoea  of  the  supra-orbital  region.  A  rebellious  anal  eczema  or 
copper-colored  intertrigo  which  resists  treatment  should  arouse  sus- 
picion. Pustular  papules  are  not  pathognomonic  even  if  combined 
with  joint-affections.  A  case  came  under  my  notice  in  which  an 
infant  had  a  varicella-like  eruption  with  a  painful  swelling  of  the 
right  elbow-joint.  A  diagnosis  of  epiphysitis  syphilitica  had  been 
made  and  the  eruption  had  been  mistaken  for  a  syphilide.  The  color 
of  the  eruption  was  not  that  of  a  syphilide.  Expectant  treatment 
and  immobility  of  the  joint  proved,  after  a  few  days,  that  the  case 
was  one  of  varicella  with  the  joint-complication  sometimes  seen  in 
that  disease. 

In  the  diagnosis  of  late  hereditary  syphilis  the  symptomatology 
is  of  service.  In  cases  with  bone-lesions  it  is  often  very  difficult  to 
differentiate  it  from  tuberculous  affections  (Fig.  93).  An  active 
course  of  treatment  then  becomes  necessary,  with  a  view  to  diagnosis; 
This  is  especially  the  case  in  arthropathies,  and  also  in  late  forms  of 
dactylitis. 

Fig.  93. 


Tuberculous   affection   of   the   bones   of   the   hand   simulating   syphilitic    disease.     Child, 

sixteen  months  of  age. 

Both  in  the  hereditary  and  acquired  forms  of  syphilis  the  Spiro- 
chgetse  are  found  in  the  blood  at  a  very  early  period  of  the  disease. 
In  the  acquired  form  it  is  found  three  weeks  before  the  appearance 
of  the  roseola.  In  the  congenital  form  it  is  found  in  the  blood  and 
internal  organs  and  in  the  lymph  which  bathes  the  skin  lesions,  such 
as  moist  papules.  Inasmuch  as  the  recognition  of  Spirochsetse  re- 
quires special  apparatus  and  skill  in  staining,  an  expert  must  decide 
their  presence.  This  is  also  the  case  with  the  Wassermann  blood 
reaction. 

Prognosis. — The  prognosis  as  to  life  depends  upon  several  factors. 
A  breast-fed  infant  is  more  likely  to  survive  than  a  bottle-fed  infant. 
The  possibility  of  complete  restoration  to  the  normal  is  slight.     The 


458  TKE    SPECIFIC    INFECTIOUS    DISEASES. 

majority  of  infants  bear  the  marks  of  the  disease  into  adult  life, 
even  under  very  favorable  conditions  of  treatment  and  environment, 
and  develop  late  in  life  the  so-called  late  symptoms  of  hereditary 
syphilis.  Some  infants  while  progressing  favorably  under  treatment, 
die  suddenly  without  apparent  cause ;  others  remain  stunted  and  deli- 
cate throughout  childhood.  Eachitis  and  its  sequelae  seem  to  be  very 
prevalent  among  infants  who  are  the  subjects  of  hereditary  syphilis. 
Treatment. — The  treatment  of  congenital  syphilis  may  be  either 
internal,  by  inunctions  or  subcutaneous  injections.  I  have  found 
internal  treatment  to  be  the  most  satisfactory.  The  effects  of  mer- 
cury are  not  so  injurious  as  is  the  case  with  the  inunction  methods. 
The  drug  employed  was  calomel  in  combination  with  the  saccharated 
ferric  carbonate  (this  was  a  favorite  remedy  with  Widerhofer)  : 

Calomel gr.  ^     (0.01). 

Ferri  carb.  sacc gr- iij  (0.18). 

Ft.  pulver. 

A  powder  of  this  size  may  be  given  every  three  hours  or  four  times 
a  day.  Some  authors  (Baginsky)  prefer  the  protoiodide  of  mercury, 
grain  i  to  2  (0.01  to  0.03).  If  there  is  intolerance  to  calomel,  satis- 
factory results  may  be  obtained  by  the  use  of  Lustgarten's  preparation 
of  hydrarg.  oxydulatum  tannicum,  in  doses  of  grains  ij  to  v  (0.1  to 
0.3),  repeated  every  three  hours  or  four  times  daily. 

If  the  rhagades,  especially  those  about  the  anus,  bleed  or  heal 
slowly,  they  should  be  stimulated  with  a  weak  solution  of  silver 
nitrate.  Calomel  should  be  dusted  upon  condylomata  lata  three 
times  daily. 

Baths  of  sublimate  are  recommended  in  severe  cases  of  pemphigus, 
but  it  is  not  often  necessary  to  resort  to  them. 

Infants  in  the  nursing  period  do  not  bear  inunctions  well.  I 
have  seen  several  cases  treated  by  this  method  which  lost  weight 
rapidly  or  died  suddenly,  and  this  has  been  the  experience  of  others 
(Monti).  The  old  method  was  to  place  grains  viij  to  xv  (0.5  to  1.0) 
of  unguentum  hydrarg.  under  the  flannel  abdominal  binder  daily, 
and  allow  it  to  be  absorbed,  or  the  same  quantity  of  ointment  was 
rubbed  in  daily  on  various  parts  of  the  body. 

Severe  rhinitis  is  best  treated  by  washing  out  the  nasal  passages 
once  a  day  with  a  solution  of  corrosive  sublimate  (1:2000).  The 
small  glass  syringe  with  a  blunt  soft-rubber  nozzle  is  best  for  this 
purpose.  After  the  syringing,  unguentum  iodoform  is  applied  to  the 
interior  of  the  nose  by  means  of  a  camel's  hair  pencil. 

How  long  should  treatment  be  continued  ?  No  matter  what 
method  of  treatment  is  adoi)ted,  mercury  should  be  administered  until 
all  discoloration  of  the  skin  has  disappeared.     To  attain  this  result 


ACUTE    ABTICULAB    EHEUMATISM.  459 

will  take  a  varying  length  of  time  in  different  cases.  After  the  skin 
is  clear  and  the  anaemia  has  disappeared,  it  is  well  to  cease  the  admin- 
istration of  drugs  and  observe  the  patient  for  further  symptoms. 
Sometimes  a  patient  will  be  brought  to  the  physician  for  the  treat- 
ment of  a  rebellious  intertrigo  long  after  all  signs  of  general  syphilis 
have  disappeared.  Such  an  intertrigo  may  have  a  copper  color,  and 
may  ulcerate,  the  ulcers  having  a  peculiar  lardaceous  appearance. 
In  these  cases,  even  if  all  other  signs  of  congenital  syphilis  are  absent, 
the  internal  administration  of  mercury  gives  brilliant  results. 

The  treatment  of  late  hereditary  syphilis  will  depend  much  upon 
the  nature  of  the  therapeutic  measures  adopted  earlier  in  life.  In 
the  majority  of  cases,  the  subjects  being  in  later  childhood  or  adoles- 
cence, it  is  well  to  begin  treatment  by  a  full  inunction  course,  conducted 
on  the  same  plan  as  with  adult  subjects  with  acquired  syphilis.  In 
addition,  if  gummatous  affections  of  the  bones  are  present,  and  if  as 
in  one  of  my  cases  visceral  lesions,  such  as  enlargement  of  the  liver, 
have  appeared,  the  patient  is  put  upon  gradually  increasing  doses  of 
iodide  of  potassium.  In  one  of  my  cases  large  doses  of  iodide  of 
potassium  failed  to  relieve  the  intense  headache.  This  patient  mar- 
ried, and  after  having  a  miscarriage  gave  birth  under  specific  treat- 
ment to  a  healthy  infant.  The  treatment  of  acquired  syphilis  does 
not  differ  from  that  of  congenital  or  late  hereditary  syphilis. 

ACUTE    ARTICULAR    RHEUMATISM. 

(Polyarthritis  Eheumatica;  BJieumatic  Fever.) 

Etiology. — Although  acute  articular  rheumatism  is  still  regarded 
by  some  authors  as  a  constitutional  disease  caused  by  disturbances  of 
nutrition  which  result  in  local  manifestations,  the  general  tendency 
is  to  regard  it  as  an  acute,  infectious  disease.  The  infectious  agent, 
whether  bacterial  or  toxic,  attack  the  serous  cavities,  such  as  those 
of  the  joints,  the  pericardium  and  endocardium,  and  the  pleura. 
The  resemblance  of  rheumatism,  especially  in  children,  to  the  infec- 
tions is  sufficiently  great  to  warrant  a  serious  consideration  of  this 
theory.  Thus  in  septic  endocarditis  in  children,  as  in  the  adult,  there 
are  symptoms  of  pain  in  the  joints.  Chronic  cases  of  endocarditis  of 
a  rheumatic  nature  in  course  of  relapse  occasionally  take  a  septic 
course.  There  are  found  circulating  in  the  blood  streptococci  of  dif- 
ferent grades  of  virulency.  Certain  diseases,  such  as  erythema  nodo- 
sum and  peliosisrheumatica,  in  which  the  joint-symptoms  are  marked, 
are  regarded  as  being  caused  by  infection  of  a  bacterial  nature. 
I  have  seen  such  a  case  of  peliosis.  In  other  diseases,  such  as 
scarlet  fever,  measles,  and  varicella,  there  are  joint-affections  which 
are  recognized  to  be  of  an  infectious  nature.     Lastly,  both  American 


460  TEE    SPECIFIC    INFECTIOUS    DISEASES. 

(Packard)  and  Englisli  writers  liave  called  attention  to  the  well- 
observed  clinical  fact  that  there  are  forms  of  rheumatism  and  endo- 
carditis which  follow  attacks  of  tonsillitis  of  the  lacunar  type  or 
accompany  them.  It  is  true  that  the  infectious  agent,  whether  bac- 
terial or  toxic  (Chvostek),  is  still  to  be  discovered.  Time  may  show 
that  not  one,  but  a  variety  of  micro-org-anisms  are  capable  of  causing 
rheumatism  of  the  acute  articular  type  in  a  susceptible  organism. 
Streptococci,  the  so-called  Streptococcus  or  DijDlococcus  rheumatica, 
have  been  found  in  the  exudate  of  the  joints  (Hlava)  and  in  the 
blood.  Staphylococcus  aureus,  citreus,  and  albus  have  been  found 
in  the  blood  (Gutmann,  Tizzoni,  Bouchard).  The  pneumococci  of 
Frankel  and  the  Diplococcus  tenuis  have  been  found  in  the  joints 
(Leyden).     Singer  has  found  similar  micro-organisms  in  the  urine. 

Heredity  is  among  the  predisposing  causes.  Children  whose 
parents  are  markedly  rheumatic,  may  suffer  severely  from  the  affec- 
tion. Cold  and  exposure  certainly  predispose  to  the  disease  or  pre- 
cipitate attacks.  The  disease  is  common  in  countries  such  as  England 
and  America,  in  which  climatic  influences  are  favorable  to  its  devel- 
opment, and  is  especially  prevalent  in  the  moist  and  cold  seasons  of 
the  year. 

Age. — Rheumatism  has  been  described  as  occurring  in  early  in- 
fancy (Jacobi).  I  have  published  a  case  in  an  infant  of  nine  months. 
Rauchfus,  Chapin,  and  others  have  also  described  cases  in  infants. 
These  cases  were  collected  by  Miller,  who,  with  his  own  case  (nine 
months),  found  19  authentic  cases  in  the  literature  in  nursing  infants. 
Although  rare  in  infancy,  rheumatism  is  not  uncommon  in  children 
from  the  fifth  to  the  tenth  year.  The  majority  of  the  cases  of  rheu- 
matism occur  between  the  tenth  and  the  twentieth  year. 

Sex. — Among  adults,  males  are  more  subject  to  the  disease.  In 
children,  however,  although  certain  observers  contend  that  it  is  more 
prevalent  among  girls,  other  statistics  show  that  it  has  the  same  fre- 
quency of  occurrence  in  the  sexes. 

Symptoms. — Certain  peculiarities,  pointed  out  by  Jacobi,  seem  to 
differentiate  acute  articular  rheumatism  of  infants  and  children  from 
the  same  affection  in  adults.  But  few  joints  are  attacked.  The  pain 
and  swelling  are  generally  not  very  marked.  The  redness  of  the 
joints  is  slight  or  altogether  absent.  The  temperature  is  rarely  high. 
The  smaller  joints,  such  as  the  maxilla,  sternoclavicular  articulation, 
and  those  of  the  vertebra3,  are  rarely  attacked.  The  larger  ones,  such 
as  the  ankle-,  knee-,  and  wrist-joints,  are  most  commonly  affected. 

Cardiac  complication  is  the  rule.  As  Jacobi  has  pointed  out, 
endocarditis  is  sometimes  the  first  manifestation  of  the  disease.  In 
many  cases  obscure  pains  in  the  joints  of  months'  duration  precede 
the  development  of  a  murmur. 


ACUTE    ABTICULAB    BHEUMATISM.  461 

Clinical  Types. — In  infants  and  young  children  the  first  signs  are 
swelling  and  pain  in  the  affected  joints.  The  infant  in  the  nursing 
period  cries,  has  fever,  and  is  restless.  On  investigation  it  is  found 
that  the  patient  favors  one, extremity,  and  shrieks  v^ith  pain  when  it 
is  touched.  Children  of  two  and  one-half  years  or  more  refuse  to 
walk,  and  will  complain  of  the  affected  joint,  ankle,  or  knee.  There 
will  be  fever  and  constitutional  symptoms.  The  ankle,  and  in  some 
cases  the  smaller  joints  of  the  foot  are  swollen.  One  of  the  knees, 
the  wrist,  and  elbow  may  also  be  swollen,  red,  and  painful.  The 
fever  rarely  rises  above  103°  or  103.5°  F.  (39.4°  C).  In  other 
cases  there  are  fever  and  restlessness,  and  sometimes  pains  of  an 
indefinite  character  in  the  joints.  A  history  of  pain  may  be  elicited 
by  careful  questioning  and  examination. 

Monarticular  pain  is  very  characteristic  of  the  form  of  rheuma- 
tism seen  in  children.  Still  and  Barlow  call  attention  to  the  fact  that 
a  pain  in  the  hip  may  be  mistaken  for  tuberculous  hip-disease,  when 
in  truth  it  is  rheumatic.  I  have  seen  these  cases,  but  have  been 
impressed  with  the  fact  that  in  infants  scurvy  also  begins  in  this  way. 

The  physician  may  find  an  angina,  slight  or  marked;  the  heart 
may  show  signs  of  endocarditis  of  an  acute  type.  There  are  pains  in 
the  joints  but  no  true  rheumatic  swellings.  The  pains  more  closely 
resemble  those  in  uncomplicated  angina  tonsillaris.  In  older  chil- 
dren, a  history  of  joint-pains  with  endocarditis  may  be  obtained.  In 
other  cases,  the  pains  in  various  joints  are  the  only  symptoms.  There 
is  no  swelling  or  redness,  and  no  endocarditis.  Some  cases  have  no 
fever.  The  classical  cases,  however,  closely  resemble  those  of  the 
affection  as  seen  in  the  adult.  There  may  be  premGnitory  symptoms, 
but  as  a  rule  the  patient  is  brought  to  the  physician  with  the  enlarge- 
ment of  the  joints  fully  developed.  After  the  joints  have  become 
enlarged  they  may  return  to  the  normal  in  a  few  days,  but  may  again 
be  the  seat  of  pain  and  swelling.  The  swelling  in  the  joints  of  chil- 
dren does  not  persist  as  long  as  in  the  adult  subject,  and  as  a  rule 
children  are  less  disabled.  In  many  cases  there  are  gastric  pains. 
The  children  do  not  show  any  greater  tendency  to  perspire  than  adults. 

Endocarditis. — Endocarditis  is  usually  a  complication  of  rheu- 
matism in  children.  Its  absence  is  rare.  Only  2  of  15  of  my  hos- 
pital cases  were  free  from  cardiac  complication.  The  most  common 
cardiac  lesion  is  found  at  the  mitral  valve  and  is  manifested  by  a 
single  systolic  murmur  at  the  apex.  Three  of  the  cases  showed  the 
presence  of  a  double  mitral  murmur.  Endocarditis  sometimes  does 
not  reveal  its  presence  by  any  symptoms,  and  is  only  discovered  on 
a  careful  examination.  In  many  of  the  cases  there  is  also  a  peri- 
cardial friction  first  heard  at  the  apex  or  base  of  the  heart.  The 
pericardial  friction  is  more  common  in  children  than  is  generally 


462  TEE    SPECIFIC    INFECTIOUS    DISEASES. 

supposed.  The  pericarditis  frequently  remains  in  the  dry  friction 
stage,  and  does  not  advance  to  effusion.  Pleuritis  and  bronchopneu- 
monia are  among  the  less  common  manifestations.  The  endocarditis 
sometimes  occasions  pain  and  distress.  The  presence  of  endocarditis 
as  an  acute  affection  in  first  attacks  of  rheumatism  has  been  dilated 
upon  in  the  section  on  Endocarditis. 

Chorea. — The  relationship  of  chorea  and  rheumatism  has  been 
discussed.  I  have  seen  a  child  of  two  and  one-half  years  born  of 
a  rheumatic  mother,  develop  first  rheumatism  and  endocarditis,  and, 
within  a  few  days,  marked  chorea.  On  the  other  hand,  in  many  cases 
of  chorea,  there  is  neither  endocarditis  nor  a  history  of  rheumatism 
in  children  or  parents.  The  statistics  of  chorea  in  hospital  service 
show  a  greater  frequency  (39  per  cent.)  of  cardiac  disease  with  or 
without  a  history  of  rheumatism  than  the  ambulatory  cases.  This  is 
explained  by  the  fact  that  only  the  severer  cases  of  chorea  come  to 
the  hospital. 

Prognosis.- — The  prognosis  of  acute  articular  rheumatism  in  in- 
fancy is  good  as  to  life.  On  the  other  hand,  it  is  a  disease  which  is 
likely  to  recur  and  to  be  complicated  by  endocarditis.  The  latter  fact 
should  cause  the  physician  to  reserve  any  definite  prognosis  until  the 
course  of  the  disease  has  been  carefully  studied.  The  prognosis  of 
rheumatic  endocarditis  can  never  be  definitely  made.  All  depends 
on  the  amount  of  damage  done  to  the  valves  and  the  frequency  of  the 
recurring  attacks. 

Treatment. — The  treatment  of  acute  articular  rheumatism  in  chil- 
dren is  not  essentially  different  from  that  followed  in  the  adult.  Sali- 
cylic acid,  bicarbonate  of  sodium,  salicylate  of  sodium,  aspirin,  and 
oil  of  wintergreen  are  the  remedies  usually  given. 

The  bowels  should  be  kept  open  with  an  alkaline  cathartic.  The 
Carlsbad  salt  or  Rochelle  salt  given  daily  is  best  adapted  for  this 
purpose.  The  patient  is  put  on  a  milk  diet ;  fruit  juices  are  allowed. 
The  patient  is  kept  in  bed.  The  affected  joints,  if  painful,  are  either 
immobilized  or  wrapped  in  cotton.  Some  prefer  to  paint  the  joints 
with  a  solution  of  oil  of  wintergreen,  and  then  wrap  them  in  cotton. 
Salicylate  of  sodium  is  given  internally  in  doses  of  grains  ij  to  v 
(0.12  to  0.3)  according  to  the  age.  A  grain  of  salicylate  of  soda  is 
given  for  every  year  of  the  age  combined  with  twice  the  quantity  of 
bicarbonate  of  soda.  Young  children  are  given  a  dose  every  three 
hours.  Older  children  are  given  doses  of  grains  vij  to  x  (0.5  to  0.6). 
The  effect  is  watched.  Salol  or  salophen  may  be  given.  The  sali- 
cylates sometimes  not  only  act  as  irritants  to  the  stomach,  but  also 
have  no  appreciable  effect  on  the  course  of  the  disease.  Aspirin  has 
in  my  hands  been  useful  in  cases  in  which  the  salicylates  were  inef- 
fective.    In  some  cases  I  give  bicarbonate  of  sodium  in  increasing 


ACUTE    AETICULAE    SHEUMATISM.  463 

doses  until  the  urine  becomes  alkaline.  Endocarditis  is  treated  on 
the  principles  laid  down  in  the  section  on  that  disease.  While  under 
treatment  the  patient  is  given  alkaline  waters.  During  convales- 
cence the  various  preparations  of  iron  are  of  great  value.  The  prepa- 
rations of  lithium  are  useful  in  cases  in  which  there  are  indefinite 
pains  in  the  joints.  The  carbonate  is  given  in  doses  of  grain  j  (0.06) 
three  times  daily.  It  is  given  in  capsule  to  older  children  after 
meals. 

The  method  of  treating  rheumatic  subjects  by  the  occasional 
administration  of  salol  or  salicylates  for  months  has  been  suggested. 
The  salicylates  upset  the  stomach,  so  that  the  alkalies  alone  are  avail- 
able. The  patient  is  given  grains  v  (0.3)  of  sodium  bicarbonate 
twice  daily.  Vichy  water  is  used  regularly.  In  some  cases  the 
tablets  of  vichy  taken  once  or  twice  daily  are  of  great  value. 

Rheumatoid  Arthritis  {Arthritis  Deformans;  Still's  Disease'). — 
This  affection  should  be  sharply  differentiated  from  all  forms  of 
chronic  or  subacute  articular  inflammation.  Charcot  and  Weil  have 
described  this  form  of  arthritis  in  children.  The  cases  are  not  com- 
mon. After  the  publication  of  my  case,  two  others  were  described 
in  the  American  literature,  one  of  the  descriptions  being  given  by 
Manges.  Cases  of  arthritis  deformans  or  rheumatoid  arthritis  in 
children  are  referred  to  by  Osier  (4  cases)  and  Henoch  (5  cases). 

Symptoms. — The  onset  of  the  disease  is -either  sudden  after  an 
exposure  to  cold  and  wet,  or  slow.  In  one  form,  after  an  onset  of 
chills  and  fever,  soreness  and  pain  in  several  joints  appear.  The 
child  is  at  first  able  to  be  about,  but,  as  the  joints  become  more  and 
more  affected,  complete  disability  results.  The  pain  in  the  joints 
becomes  so  marked  as  to  interfere  with  sleep.  After  a  few  months 
the  patients  may  be  unable  to  walk.  In  some  cases  the  enlargements 
and  pain  begin  in  the  lower  extremities  and  gradually  involve  other 
joints.  In  others  the  onset  is  slow.  The  joints  of  the  upper  and 
lower  extremities  gradually  become  painful,  and  after  repeated  attacks 
remain  swollen  and  limited  as  to  motion.  The  ends  of  the  bones  are 
enlarged  and  there  is  effusion  in  some  joints.  With  the  progressive 
involvement  of  the  joints  there  is  atrophy  of  the  muscles,  as  in  the 
adult  form  of  the  disease.  When  the  disease  is  fully  developed  the 
condition  is  pitiable.  In  my  case  almost  every  joint  in  the  body, 
including  those  of  the  cervical  vertebrae,  was  involved;  the  temporo- 
maxillary  articulation,  the  shoulder,  the  elbow,  the  small  finger-joints, 
the  hips,  knees,  ankles,  and  toes,  were  all  affected.  The  patient  slept 
in  a  semi-upright  posture,  and  had  to  be  carried  from  place  to  place. 
There  was  very  limited  and  painful  motion  in  all  the  affected  joints 
(Fig.  94). 

Brabazon  found  that  of  100  cases  of  this  affection,  only  3  per 


464 


THE    SPECIFIC    INFECTIOUS    DISEASES. 


cent,  occurred  between  the  ages  of  five  and  fifteen  years.  Two 
theories  have  been  advanced  to  exjDlain  this  j  oint-aif ection ;  one,  that 
of  Charcot  and  Weil,  is  the  neurotic  theory,  which  is  plausible  because 
of  the  bilateral  nature  of  the  aft'ection,  the  atrophy  of  the  muscles 
around  the  joints,  the  changes  in  the  skin  which  becomes  in  time 
tense  and  shining,  and  the  enlargement  of  the  ends  of  the  bones  which 
enter  into  the  formation  of  the  joints.  The  infectious  theory  is  sup- 
ported by  the  fact  that  there  is  in  many  cases  a  diurnal  fluctuation  of 
temperature  of  a  degTee  or  a  fraction  of  a  degTee  above  the  normal. 

Fig.  94. 


Rheumatoid  arthritis  in  a  child  seven  years  old.     Deformity  of  all  the  joints  with 
fixation.     Child  forced  to  assume  this  attitude  awake  and  in  sleep. 


The  lymph-nodes  are  enlarged ;  the  liver  and  spleen  are  also  enlarged 
in  some  cases  (see  Still's  Disease).     The  heart  is  not  usually  involved. 

Prognosis. — The  prognosis  as  to  life  is  good. 

Treatment. — Treatment  Ijy  massage,  warm  baths,  and  patient 
manipulation  of  the  joints  under  anesthesia,  may  effect  slight  im- 
provement. In  my  case  improvement  was  noted  after  a  year  of  con- 
stant treatment.     Iodide  of  potassium  is  the  only  drug  which  relieves 


ACUTE    ABTICULAB    RHEUMATISM. 


465 


the  pain.  In  some  cases  it  exerts  a  favorable  influence  upon  the 
course  of  the  disease. 

Still's  Disease. — This  form  of  rheumatoid  arthritis  probably  be- 
longs in  the  same  class  as  that  just  discussed.  It  is  described  by 
Still  and  is  thought  by  him  to  be  essentially  peculiar  in  its  symptom- 
atology to  children. 

Etiology. — It  is  apparently  an  acute  infection  of  obscure  etiology, 
rheumatoid  in  its  nature,  afl'ecting  for  the  most  part  the  larger  joints, 
especially  the  elbows,  wrists,  knees,  ankles,  and  in  some  cases  the 
smaller  joints,  especially  of  the  fingers. 

Fig.  95. 


still's  Disease  in  boy   of  eight  years.     Large   and  small   joints   affected,   also  cervical 
vertebrae ;  enlarged  lymph  nodes,  liver  and  spleen. 


Symptoms. — It  is  accompanied  by  periods  of  pyrexia  and  hyper- 
pyrexia and  what  is  mainly  characteristic,  enlargement  of  the  lymph- 
nodes,  liver,  and  in  most  cases  of  the  spleen.  The  joints  of  the  cer- 
vical vertebrae  were  involved  in  the  cases  described  by  Still.  There 
was  no  clinical  involvement  of  the  heart,  though  postmortem  there 
was  adherent  pericardium  in  some  cases  and  mitral  involvement  in 
another  (Fig.  95). 

The  condition  in  half  the  cases  began  before  the  second  dentition, 
girls  being  more  often  affected  than  boys.     The  enlargement  of  the 

30 


466  THE    SPECIFIC   INFECTIOUS   DISEASES. 

joints  is  fusiform  without  redness  but  with  varying  amount  of  ten- 
derness. There  may  be  limitation  of  pain  and  in  three  of  my  cases 
there  was  limitation  of  motion.  The  lymph-nodes  affected  are  the 
axillary,  epitrochlear,  and  posterior  cervical.  In  some  cases  the 
spleen  was  not  enlarged.  Still  wishes  to  place  these  cases  in  a  dis- 
tinct class  on  account  of  the  enlarged  lymph-nodes,  spleen,  and  liver. 
I  have  had  four  cases  of  this  form  of  rheumatoid  arthritis,  one  of 
which  made  a  very  excellent  recovery. 

Treatment. — The  treatment  is  1he  same  as  in  rheumatoid  arthritis. 

Other  Forms  of  So-called  Rheumatism. — (Rheumatoid  Affec- 
tions).— There  are  three  forms  of  joint-affection  which  it  is  not  yet 
advisable  to  class  with  true  articular  rheumatism,  but  which  are  con- 
stantly and  incorrectly  called  rheumatic. 

Gonorrhceal  Form. — The  gonorrhoeal  form  of  rheumatoid  affection 
is  seen  in  infants  and  children  who  suffer  from  gonorrhoeal  vulvo- 
vaginitis or  urethritis  (Hartley,  Koplik,  Moncorvo).  It  may  be 
monarticular  or  many  joints  may  be  affected.  It  is  not,  as  a  rule, 
combined  with  endocarditis.     I  know  of  no  such  case  in  the  literature. 

Peliosis. — Cases  of  so-called  peliosis  rheumatica  closely  resemble 
acute  articular  rheumatism.  I  have  seen  several  in  older  children. 
In  one  there  were  for  weeks  repeated  painful  swellings  of  the  joints, 
with  purpuric  eruption  about  them.  The  gastric  pains  and  critical 
sweats  so  often  seen  in  rheumatism  were  present.  These  cases  rarely 
present  a  temperature  above  100.5°  F.  (38°  C).  They  show  no 
cardiac  lesion. 

Tonsillitis  with  Joint-pains  and  Endocarditis, — Under  the  proper 
heading  I  have  referred  to  cases  of  tonsillitis  with  indefinite  pains  in 
the  joints  and  complicated  with  endocarditis. 

Erythema  Nodosum. — I  have  seen  many  cases  of  erythema  nodosum 
in  children.  In  all,  the  typical  painful  swellings  on  the  anterior 
aspect  of  the  tibia  were  present.  There  were  also  joint-pains,  but  in 
only  5  cases  could  I  establish  the  presence  of  an  endocardial  murmur. 
I  am  therefore  not  willing  to  accept  without  reserve  the  contention  of 
French  authors  that  endocarditis  is  frequent  in  these  cases. 

Subcutaneous  Rheumatic  Nodules. — The  so-called  subcutaneous 
rheumatic  nodules  are  seen  in  children  less  frequently  in  this  country 
than  in  England.  They  occur  in  endocarditis,  and  were  present  in 
20  per  cent,  of  Coult's  cases  (Donkin).  They  may  be  present  in  the 
absence  of  fever  or  in  the  febrile  stage  of  rheumatism.  They  may  be 
minute  or  of  the  size  of  an  almond.  They  appear  in  crops,  and  may 
alternately  appear  and  disappear  for  weeks.  The  nodules  occur 
about  the  joints,  elbows,  knees,  patella,  over  the  vertebrae  and  scapula, 
and  are  freely  movable  under  the  skin  which  is  not  discolored.  I 
have  seen  them  in  a  case  of  rheumatoid  arthritis,  and  also  in  one  of 
peliosis  rheumatica. 


ACUTE    AETICULAB    EHEUMATISM.  467 

Muscular  Rheumatism. — Muscular  rheumatism  is  rare  in  infancy 
and  childhood.  Henoch  describes  cases  of  contracture  of  the  muscles 
of  the  neck  and  of  the  nape  of  the  neck.  Among  such  contractures 
are  forms  of  torticollis  which  are  said  to  have  a  rheumatic  origin.  I 
have  met  many  cases  of  torticollis  in  v^hich  v^ith  the  contracture  there 
was  swelling  of  the  cervical  lymph-nodes.  In  such  cases  I  have  found 
eczematous  affections  of  the  scalp.  It  is  possible  that  there  was  an 
acute  infectious  neuritis  or  myositis.  There  may,  however,  be  cases 
resting  on  a  purely  rheumatic  basis.  All  forms  of  torticollis  due  to 
hsematoma  of  the  sternomastoid  muscles  or  to  cervical  bone  disease, 
glandular  disease,  or  neuritis  should  be  excluded  before  a  definite  con- 
clusion is  reached.  Henoch  also  refers  to  contractures  of  the  abduc- 
tors of  the  thigh  which  are  of  rheumatic  origin.  I  have  never  seen 
cases  of  the  kind. 


SECTION  VI. 

DISEASES  OF  THE  MOUTH,  TONGUE  AND 
(ESOPHAGUS. 

DISEASES    OF    THE    MOUTH. 

Physiological  Facts. — The  mouth  of  the  infant  up  to  about  the 
eighth  month  is  devoid  of  teeth,  and  thus  nature  indicates  that  the 
infant  is  not  prepared  to  masticate  solid  food.  The  salivary  glands 
show  very  little  activity  in  the  first  three  months  of  infancy,  the  secre- 
tion of  saliva  at  this  time  being  small  in  quantity. 

In  the  newborn,  before  it  has  partaken  of  food,  the  reaction  of 
the  secretions  of  the  mouth  is  neutral  or  slightly  alkaline.  Though 
an  amylolytic  ferment  is  present  in  the  secretion  of  the  parotid  gland 
in  the  first  days  after  birth  (Zweifel),  the  function  of  this  ferment  is 
as  yet  a  matter  of  speculation,  inasmuch  as  the  food  of  the  newborn 
breast-fed  infant  contains  nothing  in  which  the  action  of  such  a  fer- 
ment might  be  manifest. 

Of  interest  is  the  act  of  nursing,  which  in  the  infant  takes  the 
place  of  the  process  of  mastication. 

Physiology  of  the  Act  of  Nursing. — If  an  attempt  is  made  to  feed 
the  newborn  infant  with  fluids,  either  from  the  spoon  or  pipette,  there 
follows  an  abortive  attempt  at  swallowing,  accompanied  by  choking; 
it  thus  requires  some  skill  and  practice  to  induce  the  newborn  infant 
to  swallow  fluids  administered  in  this  way.  Not  so  with  the  breast. 
The  newborn  child  instinctly  takes  the  nipple  of  the  breast,  and  nurses 
without  previous  education  or  preparation.  The  act  of  nursing,  there- 
fore, is  purely  reflex. 

Thompson  has  described  the  so-called  lip  reflex.  If  the  infant  at 
rest  or  sleeping  is  gently  tapped  or  touched  on  the  upper  or  lower 
lip  in  the  neighborhood  of  the  commissure,  there  follows  a  reflex 
movement  of  the  lips.  If  they  have  been  separated,  they  close 
and  form  themselves  into  a  pouting  position;  in  other  words,  they 
purse  themselves  as  if  in  readiness  to  take  something  into  the  mouth. 
The  breast-nipple,  therefore,  performs  a  function  for  the  infant 
similar  to  that  of  the  finger  in  producing  this  so-called  reflex  of  the 
lip.  The  nipple  once  having  touched  the  lips  of  the  infant  is  re- 
ceived by  the  pursed  lips  into  a  funnel-shaped  opening,  and  the  lips 
grasp  the  nipple  and  some  of  the  adjacent  skin.  It  is  received  be- 
tween the  hard  palate  above  and  the  superior  surface  of  the  tong-ue 

468 


DISEASES    OF    THE    MOUTH.  469 

below.  The  lower  jaw  aids  in  making  tlie  contact  between  the  lips 
and  the  nipple  complete.  The  act  of  nursing  itself  is  the  estab- 
lishment, first,  of  a  negative  pressure,  caused  by  the  act  of  suction, 
equal  to  0.5  to  0.9  centimetres  of  mercury.  This  alone  would  not 
determine  the  flow  of  milk  into  the  mouth  of  the  nursling  were  it 
not  for  the  muscular  pressure  from  below  of  the  lower  jaw.  The 
combined  force  of  the  negative  pressure  produced  by  the  act  of  suction 
and  the  muscular  pressure  from  below  on  the  nipple  as  it  joins  the 
breast  is  equal  to  4  centimetres  of  mercury.  This  has  been  shown 
experimentally  to  be  quite  sufficient  to  determine  a  steady  flow  of 
milk  from  the  breast  into  the  mouth  of  the  nursling.  It  takes  from 
three  to  four  acts  of  suction  and  muscular  pressure  to  fill  the  mouth 
sufficiently  to  cause  one  act  of  swallowing  on  the  part  of  the  infant. 

Landmarks  of  the  Normal  Mouth. — There  are  certain  localities 
of  the  mucous  membrane  of  the  mouth  which  are  especially  liable  to 
aphthae  or  ulceration.  Among  these  we  must  mention  the  mucous 
membrane  over  the  hamular  process  of  the  palate  bone,  where  it  is 
normally  paler  than  the  surrounding  tissue.  This  pale  area  on  either 
side  of  the  median  line  may  be  the  seat  of  the  so-called  Bednar's 
aphthae.  Midway  in  the  raphe  of  the  hard  palate  in  most  newborn 
infants  are  seen  one  or  two,  at  most  three,  yellowish- white,  sago-like 
objects;  these  are  called  Epstein's  pearls,  because  they  were  first 
described  by  this  clinician.  They  are  collections  of  epithelial  cells, 
the  remains  of  embryonal  formations.  These  epithelial  pearls  are 
quite  susceptible  to  traumatism,  and  if  injured  in  any  way  become 
the  seat  of  ulceration.  Laterally  on  the  hard  palate  over  the  alveolar 
process,  above  and  below  the  mucous  membrane  is  thin  and  has  a 
white  reflex.  Any  slight  traumatism  in  this  locality  may  cause  ulcer- 
ation. The  tonsils  of  the  newborn  infant  are  scarcely  visible.  The 
posterior  pharyngeal  wall  is  glossy,  of  a  bluish-pink  color.  On  closer 
examination  of  the  fauces  of  infants,  bodies  resembling  drops  of  dew 
or  vesicles  are  seen  just  in  front  of  the  tonsil.  These  are  collections 
of  lymphoid  tissue,  and  are  normal  to  the  infant's  mouth.  They 
may  become  inflamed  and  form  aphthous  ulcerations,  and  when  so 
inflamed  are  called  herpes  of  the  tonsil.  There  are  also  visible  on  the 
soft  palate  of  children  minute  miliary,  transparent  bodies  resembling 
vesicles,  which  are  likely  to  enlarge  in  any  disease  affecting  the 
mucous  membrane  of  the  mouth,  as  in  the  exanthemata.  These  also 
are  aggregations  of  lymphoid  tissue. 

Bacteria  of  the  Mouth. — The  bacterial  flora  of  the  mouth  of  the 
infant  have  been  the  subject  of  investigation  by  Lewkowicz.  Only 
the  leading  flora  can  be  mentioned  here :  the  pneumococcus,  which  is 
constantly  present  but  not  pathogenic ;  the  streptococcus,  in  long 
chains  similar  to  the  pyogenic  variety  but  not  pathogenic ;  the  Strep- 
tococcus salivse  of  Veillon,  the  Streptococcus  aggregatus  of  Seitz,  the 


470  DISEASES    OF    THE    MOUTH. 

Staphylococcus  pyogenes  albus,  the  Streptococcus  intestinalis  or  en- 
teritidis  of  Escherich,  the  Micrococcus  candidans  (Fliigge),  the  Ba- 
cillus acidiphilus  of  Moro,  the  most  constant  and  frequent  of  the 
bacillary  group ;  and  the  pseudodiiDhtheria  bacillus.  There  are  also, 
strange  to  say,  anaerobic  bacteria  to  be  found  in  the  mouth  of  infants, 
the  most  important  being  the  Bacillus  bifidus  communis  of  Tissier. 
In  all  there  are  23  varieties  of  bacteria  normal  to  the  buccal  cavity  of 
nursing  infants. 

Normal  Dentition. — The  teeth,  both  temporary  and  permanent, 
are  contained  in  the  so-called  tooth-sacs,  which  are  situated  in  the 
alveolar  process  of  the  upper  and  the  body  of  the  lov^er  jaw.  The 
formation  of  these  sacs  begins  in  the  sixth  month  of  foetal  life,  by  a 
coalescence  of  the  folds  and  papillae  formed  in  the  jaw.  There  are 
twenty  temporary  teeth,  and  the  sacs  of  the  permanent  teeth  are 
situated  against  the  posterior  wall  of  the  sacs  of  the  temporary  teeth, 
and  probably  communicate  with  them.  As  a  result  of  the  growth 
of  the  roots  of  the  teeth,  the  temporary  teeth  are  pushed  through  the 
cartilaginous  border  of  the  jaw  and  the  mucous  membrane,  and  thus 
appear  externally. 

Temporary  or  Milk  Teeth. — The  eruption  of  the  temporary  or  milk 
teeth  begins  about  the  sixth  or  seventh  month  with  the  lower  incisors, 
and  ends  about  the  third  year  with  the  posterior  molars.  The  erup- 
tion of  the  teeth,  even  in  normal  infants,  varies  within  wide  limits, 
some  infants  being  precocious  and  others  late  in  this  process,  without 
necessarily  showing  any  signs  of  bone  disease,  such  as  rachitis.  We 
might  gToup  the  eruption  of  the  milk  teeth  into  five  groups  as  follows : 
The  first  would  include  the  two  lower  incisors,  which  erupt  at  from 
the  seventh  to  the  ninth  month.  There  is  then  an  interval  of  from 
three  to  nine  weeks,  when  the  second  group,  consisting  of  the  four 
upper  incisors,  appears  from  the  eighth  to  the  tenth  month.  After 
this  there  is  an  interval  of  from  six  to  twelve  weeks,  when  the  third 
group  appears.  This  consists  of  the  first  molars  and  two  lower  lateral 
incisors,  which  erupt  from  the  twelfth  to  the  fifteenth  month.  An 
interval  of  three  months  then  occurs,  and  the  canines  appear  in  the 
fourth  group  from  the  eighteenth  to  the  twenty-fourth  month.  There 
is  an  interval  of  two  months,  and  the  four  second  molars  ap]iear.  At 
the  fifth  or  sixth  year  the  third  molar  appears,  and  then  the  second 
dentition  begins. 

As  exceptions  to  the  al)ove  order,  we  may  have  the  two  upper 
lateral  incisors  delayed  until  the  sixteenth  month;  the  two  upper 
incisors  and  the  four  posterior  molars  may  be  delayed  as  late  as  the 
thirty-sixth  month.  At  the  twelfth  month  an  infant  should  have  the 
four  upper  and  two  lower  central  incisors,  with  two  lower  lateral 
incisors  coming.  The  lower  incisors  may  not  appear  until  the  eighth 
or  ninth  month,  and  then  be  followed  rapidly  by  others.     I  have  seen 


DISEASES    OF    THE    MOUTH. 


471 


several  infants  with  one  or  two  incisors  at  birth ;  they,  as  a  rule,  were 
imperfectly  formed  and  resembled  canines.  These  prematurely 
erupted  teeth  should  be  extracted  if  they  interfere  with  nursing  and 
lacerate  the  nipple  of  the  breast.  In  some  cases  the  upper  incisors 
may  appear  first,  and  rarely  canines  may  appear  before  molars. 

Permanent  Teeth. — The  second  dentition  begins  at  the  end  of  the 
sixth  or  seventh  year  with  the  eruption  of  the  first  molar  behind  the 
second  temporary  molar.  The  milk  teeth  at  this  time  loosen  because 
their  arteries  become  obliterated,  the  nerves  disappear,  the  alveolar 
sacs  enlarge,  and  they  fall  out  or  may  become  carious.  The  perma- 
nent teeth  appear  in  the  second  dentition,  as  has  been  said,  very  much 
in  the  order  that  the  milk  teeth  appear — the  central  incisors  about 
the  eighth  year,  the  lateral  incisors  at  the  ninth  year,  and  the  last 
molars  from  the  eighteenth  to  the  twentieth  year,  or  even  later. 

Abnormal  Dentition. — Rachitis. — Rachitis  is  a  common  cause  of 
delayed  dentition.  Artificially-fed  infants  are  backward  in  cutting 
their  first  incisors.  It  is  common  to  see  bottle-fed  infants  cutting  the 
lower  anterior  incisors  at  the  ninth  month.  The  infants  may  be  in 
other  respects  normal.  Rachitis  affects  the  teeth  of  the  first  denti- 
tion mostly,  but  may  influence  the  form  and  structure  of  the  teeth  of 
the  second  dentition.  The  teeth  of  the  first  dentition  in  rachitis  are 
easily  broken  and  are  unnaturally  white.  In  many  cases  the  anterior 
incisors  show  an  incurvation  on  the  lower  cutting  edge,  which  is  often 
mistaken  for  Hutchinson's  deformity.  The  first  teeth  in  rachitis  are 
easily  eroded.  It  is  not  uncommon  to  see  a  rachitic  infant  with  its 
whole  dental  system  in  process  of  decay.  The  permanent  teeth  pre- 
sent abnormalities  in  inordinate  size  and  longitudinal  furrows. 

Sjrphilis. — The  permanent  teeth  are  affected  by  syphilis  in  a  char- 
acteristic fashion. 

Fig.  96. 


Hutchinson's  teeth  in  a  boy,  twelve  years  of  age. 


Hutchinson  s  Teeth. — Hutchinson's  teeth  are  so  called  because 
they  were  first  described  by  Jonathan  Hutchinson.  They  are  the 
only  teeth  of  the  permanent  set  which  are  pathognomonic  of  congen- 
ital or  very  early  acquired  syphilis  (infancy)  (Fig.  96).     In  a  large 


472 


DISEASES    OF    THE    MOUTH. 


experience  with  syphilis  in  infancy  and  childhood  I  have  seen  but 
few  perfect  examples  of  these  teeth.  The  teeth  presenting  the  de- 
formity are  the  central  upper  incisors  of  the  permanent  set,  and  these 
only.  "  These  teeth  show  a  central  single,  rather  broad  notch."  In 
this  notch  the  dentine,  lightly  covered  by  enamel,  is  exposed.     It  is 


Fig.  97. 


Permanent  teeth  deformed  through  stomatitis  in  early  childhood,  resembling  Hutchin- 
son's teeth.     Female  child,  nine  years  of  age. 


Fig.  98. 


seen  as  a  ridge  in  the  incurvation.  The  teeth  are  shorter  and  broader 
than  is  natural,  and  almost  always  have  their  angles  sloped  oif .  They 
are  thus  narrower  at  their  cutting  edge  than  higher  up.  They  are 
seldom  or  never  of  good  color,  and  frequently  are  not  placed  quite 
straight,  but  slope  either  toward  or  away  from  each  other.  Teeth 
which  are  the  seat  of  erosion  may  resemble  Hutchinson's  teeth  (Fig. 

97).  Fournier  has  described  teeth  in  the 
temporary  set  which  closely  resembled  Hutch- 
inson's teeth.  I  have  met  an  exquisite  ex- 
ample of  such  teeth  in  an  infant  sixteen 
months  old,  the  subject  of  syphilis  (Fig.  98). 
In  syphilitic  subjects  we  find  the  follow- 
ing def  onnities  in  the  permanent  teeth.  These 
peculiarities  are  not  characteristic  of  syphilis 
alone,  but  are  found  in  those  who  are  not 
syphilitic,  but  have  suffered  from  stomatitis  or  dyscrasia  of  some  kind. 
The  changes  are  bilateral  and  symmetrical. 

Dental  Erosions. — The  most  important  erosions,  such  as  those  of 
Hutchinson  just  described,  affect  the  central  incisors.  Other  erosions 
give  the  teeth  an  incurvated  appearance  on  their  cutting  edge.  In 
this  incurvation  is  seen  a  supernumerary  crown  ribbed  in  a  longitu- 


Central  upper  Incisors  of 
the  first  dentition  resem- 
bling Hutchinson's  teeth. 
Syphilis  of  the  flat  and 
long  bones.  Child,  sixteen 
months  of  age. 


DISEASES    OF    THE    MOUTH. 


Al?, 


dinal  direction  (Figs.  99  and  100).  The  whole  may  be  mistaken  for 
Hutchinson's  deformity.  They  result  from  malnutrition  or  stoma- 
titis with  faulty  formation  of  dentine  and  enamel  deposit  in  the 
eruptive  period  of  the  permanent  teeth.  The  first  molars  show  very 
characteristic  deformities,  which  Fournier  places  next  in  importance 
to  those  of  the  Hutchinson  teeth,  but  does  not  regard  as  pathog- 
nomonic of  syphilis,  although  they  are  met  in  syphilitic  subjects. 
This  deformity  of  the  first  molars  is  shown  in  Fig.  101,  taken  from  a 


Fig.  99. 


I'IG.   100. 


Upper  central  incisors,  with  erosions 
not  syphilitic. 


Lower  incisors,  with  erosions  not  syphilitic. 
Child,  eight  years  of  age. 


child  who  showed  other  erosions,  but  gave  no  history  of  syphilis.  I 
have  seen  these  erosions  very  well  marked  in  children  who  had  posi- 
tive syphilitic  manifestations.  The  top  of  the  crown  is  constricted, 
and  there  appears  to  be  a  double  crown.  Erosions  are  also  seen  in 
the  canine  teeth. 

Microdontism. — The  teeth  are  quite  small,  but  if  cared  for  remain 
perfect  in  shape,,  pearly  and  transparent.     They  are  seen  in  children 


Fig.  101. 


Fig.  102. 


Erosion  of  molars,  not  nec- 
essarily syphilitic. 


Molar  tooth,  showing  erosion  at 
crown.  Boy,  twelve  years  of  age  ; 
same  patient  as  with  Hutchinson's 
teeth. 


whose  parents  may  have  suffered  from  syphilis.  The  children  may 
also  have  obstinate  eczema  of  the  anus  (parasyphilitic).  Micro- 
dontism may  occur  also  as  a  result  of  any  non-syphilitic  dyscrasia. 

Dental  Infantilism. — Dental  infantilism,  described  by  Fournier, 
occurs  in  children  who  are  syphilitic.  Small  teeth  presenting  ero- 
sions are  interspersed  among  teeth  which  are  normal  in  size  and  shape. 

Amorphism. — Amorphism,  or  the  tendency  of  a  tooth,  such  as  the 


474  DISEASES    OF    THE    MOUTH. 

incisor,  to  take  the  shape  of  a  canine,  has  been  noted  by  Fournier.  I 
have  also  met  with  cases  of  this  deformity  in  congenitally  syphilitic 
children.  It  is  seen  in  children  who  have  had  syphilis,  but  may  be 
met  with  in  those  who  have  no  snch  history. 

Children,  subjects  of  syphilis,  do  not  always  present  deformities 
of  the  teeth.  In  a  girl  of  fourteen  years,  who  gave  a  history  of  infan- 
tile syphilis,  and  who  had  late  manifestations,  such  as  gummata  in 
almost  all  the  bones,  joint-affections,  and  gummata  of  the  liver,  the 
teeth,  both  ujDper  and  lower,  were  normal  and  of  great  beauty. 

Pathology  of  Dentition. — The  period  of  infantile  dentition  is 
one  of  gTeat  physiological  activity  and  growth.  The  organism  is 
forming  at  this  time.  The  nervous  system  is  in  a  condition  of  insta- 
bility. The  gut  is  exposed  to  and  is  very  susceptible  to  all  varieties 
of  infections.  During  this  period  the  infant  or  child  suffers  from  a 
number  of  diseases  and  exhibits  a  variety  of  symptoms  which  in 
former  times  were  difficult  of  interpretation.  With  advancing  knowl- 
edge and  the  possibility  of  making  more  accurate  diagnoses  than  were 
formerly  feasible,  the  diseases  incidental  to  dentition  have  become 
more  a  matter  of  speculation.  There  are  clinicians  of  note  who  still 
believe  that  irritation  of  the  trigeminal  branches  by  an  erupting  tooth 
may  cause  reflex  eclampsia.  It  is  difficult,  and  not  necessary,  to 
pass  here  on  the  status  of  that  section  of  infantile  pathology  which 
treats  of  the  disorders  incident  to  dentition.  In  the  presence  of  mys- 
tifying symptoms  the  physician  should  make  a  very  careful  examina- 
tion, in  order  to  make  a  diagnosis.  Clinical  observation  of  a  case 
for  a  few  days,  and  accurate  registration  of  the  pulse,  respiration, 
and  temperature  every  three  hours,  may  show  that  the  diagnosis  of 
dentition  must  give  way  to  something  more  tangible. 

Should  the  Gums  be  Incised? — I  have  often  found  the  tooth- 
sacs  to  be  swollen  and  the  seat  of  painful  distention  just  before  the 
eruption  of  the  teeth.  In  one  case  the  tooth-sac  was  distended  by  a 
hemorrhage  into  its  cavity.  Many  cases  of  tense  tooth-sacs  or  hemor- 
rhage into  such  tooth-sacs  are  evidences  of  scurvy  or  disturbed  nutri- 
tion. Under  these  conditions  I  have  not  yielded  to  the  entreaties 
of  the  mother  to  lance  the  gums.  I  have  seen  no  ill  effects  result 
from  this  laissez  faire  method.  Very  painful  ulcerations  result  from 
friction,  and  uncontrollable  hemorrhage  may  follow  incision.  In 
cases  in  which  the  sacs  are  distended,  the  functions  of  the  stomach  and 
gut  should  be  kept  normal,  in  order  that  complications  may  not  be 
added  to  existing  conditions.  In  rare  cases  I  have  seen  suppuration 
in  the  tooth-sac,  and  have  incised.  In  cases  of  scurvy  in  which  the 
tooth-sacs  are  distended  and  bluish  in  appearance,  treatment  of  the 
scurvy  improves  this  condition. 

Ulcerations  or  Erosions  of  the  Angles  of  the  Mouth  (Fr.,  Per- 


DISEASES    OF    THE    MOUTH.  475 

Uchej  Grer,  (Faule  Echen)  Epstein). — Definition. — This  is  a  form 
of  non-specific  ulceration  or  rhagade  occurring  at  the  corners  of  the 
mouth,  affecting  the  vermilion  border  of  the  mucous  membrane. 

Occurrence. — This  affection  is  seen  in  children  who  present  other 
signs  of  malnutrition,  such  as  scrofulosis  or  lymphatism.  They  are 
anaemic,  suffer  from  nasopharyngeal  catarrh  or  skin  eruptions,  aiid 
live  in  unhygienic  surroundings.  The  disease  is  seen  in  children 
under  two  years  of  age,  and  mostly  beyond  that  period.  The  disease 
is  confined  to  the  corners  of  the  mouth,  and  may  be  strictly  limited 
to  them,  though  the  author  has  often  seen  it  combined  with  erosions 
of  the  alEe  nasi. 

Symptoms. — These  erosions,  fissures,  or  rhagades  consist  of  lineal 
ulcers  of  the  corners  of  the  mouth,  which  may  have  a  red  base  and 
elevated  borders,  or  the  base  and  borders  may  have  a  bluish  tinge, 
resembling  mucous  patches.  In  these  children  the  question  of  diag- 
nosis of  these  rhagades  from  those  due  to  syphilis  is  constantly  arising. 
The  induration  of  the  base  of  the  ulcer  which  is  present  in  syphilis 
is  absent  in  the  non-specific  rhagade.  The  surface  of  the  ulcer  has 
a  more  lardaceous  appearance  in  syphilis  as  a  rule,  the  lips  are  in- 
volved, and  there  are  mucous  patches  elsewhere. 

The  affection  which  we  are  describing  is  found  isolated  and  lim- 
ited to  the  corners  of  the  mouth.  The  borders  of  the  rhagade  may 
be  surrounded  by  minute  pustules.  The  rhagade  is  symmetrical, 
involving  both  sides  of  the  mouth.  It  is  not  painful  unless  the  mouth 
is  put  on  the  stretch  or  acid  substances  applied  to  the  base  of  the  ulcer. 
In  other  cases  the  borders  of  the  rhagades  are  raised  and  indurated. 
I  have  seen  a  large  number  of  these  rhagades ;  some,  at  least,  so  closely 
resembling  a  syphilitic  lesion  as  always  to  warrant  a  careful  exclusion 
in  each  case  of  this  affection. 

Diagnosis. — The  diagnosis  offers  no  difficulty,  though  it  is  an 
affection  which  rarely  comes  to  the  physician  to  be  treated  as  an 
isolated  disease,  and  is  generally  met  in  combination  with  other  dis- 
eases. I  have  seen  it  in  children  suffering  from  typhoid  fever.  The 
disease  may  be  mistaken  for  diphtheritic  infection,  inasmuch  as  in 
some  cases  the  base  of  the  rhagade  is  covered  by  a  pseudomembranous, 
whitish  deposit.  The  culture  tube  will  decide  the  true  nature  of  the 
lesion  in  such  cases. 

Course.^ — The  duration  of  the  disease  extends  over  a  period  of  two 
or  three  weeks ;  if  untreated,  it  usually  becomes  chronic.  I  have  suc- 
ceeded in  curing  these  rhagades  by  touching  them  once  daily  with  a 
10  per  cent,  solution  of  nitrate  of  silver,  and  then  applying  the  oint- 
ment of  red  oxide  of  mercury.  Another  remedy  is  the  application  of 
a  solution  of  corrosive  sublimate  (1 :  2000). 

Bednar's  Aphthse. — Bednar's   aphthae,   named   after  the   distin- 


476 


DISEASES    OF    THE    MOUTH. 


guished  Viennese  pediatrist  wlio  first  described  them,  are  two  sym- 
metrical ulcerations  over  the  hamular  process  of  the  palate  bone,  seen 
in  the  newly  born  or  very  young  infant  (Fig.  103).  They  are  the 
result  of  traumatism.  They  are  seen  in  infants  in  whom  the  mouth 
has  been  too  scrupulously  cleansed.  In  these  cases  the  finger  of  the 
nurse  in  the  act  of  cleaning  impinges  against  the  hamular  process  of 
the  palate  bone  and  abrades  the  epithelium.  Any  bacteria  which 
may  be  present  in  the  mouth  or  on  the  finger  thus  gain  foothold  and 
ulceration  results.  Epstein  has  shown  that  in  the  newly  born  infant 
such  ulcers  may  be  the  starting-point  of  a  general  sepsis. 

Fig.  103. 


View  of  the  hard  and  soft  palate.     Lateral  ulcerations — so-called  Bednar's  aphthae. 


The  infant  may  refuse  to  nurse,  or  if  it  does  attempt  to  do  so, 
the  pain  caused  by  the  act  of  suckling  causes  it  to  desist.  There  may 
be  intestinal  disturbance,  manifested  by  greenish  stools,  and  there 
may  be  infection  of  the  gut  by  the  bacterial  flora  of  the  ulceration. 

Treatment. — The  ulcer  should  neither  be  washed  nor  traumatized. 
The  rest  of  the  mouth  and  tongue  should  be  washed  gently  twice  daily 
with  a  saturated  aqueous  solution  of  boric  acid.  The  ulcers  should 
be  touched  once  or  twice  a  day  with  a  ten  per  cent,  solution  of  silver 
nitrate  applied  with  a  small  piece  of  cotton  on  an  applicator. 

Sprue  {Thrush;  Muguet  (Fr.)  ;  Soor  (Ger.)). — Sprue  is  a  para- 
sitic growth  on  the  mucous  membrane  of  the  buccal  cavity  of  the 
infant.  It  may  spread  to  the  nose  in  cases  of  cleft  palate ;  in  other 
cases  it  may  spread  to  the  pharynx,  larynx,  oesophagus  (Parrot,  and 
even  to  the  stomach  (Parrot,  Henoch,  JSTorthrup)).  The  latter  sit- 
uation is  not  favorable  to  its  growth.  The  parasite  has  been  found 
in  the  intestinal  movements  of  infants  suft'ering  from  the  disease. 


DISEASES    OF    THE    MOUTH.  477 

Nature. — Sprue  is  a  mould  fungus.  Its  classification  by  various 
authors  varies  with  the  species  examined.  Older  authors  classed 
sprue  vt^ith  the  oi'dium  as  Oidium  albicans.  Rees,  Grawitz,  and 
Kehrer  classified  it  as  a  Mycoderma  albicans,  consisting  of  conidia 
and  mycelia.  Plant  classifies  it  as  a  common  mould  fungus  (Monilia 
Candida). 

In  the  early  stages  it  presents  large  or  small  irregular  whitish 
masses.  These  may  at  first  be  very  minute^  covering  only  the  sum- 
mits of  the  papillae  of  the  tongue.  On  the  buccal  mucous  membrane 
they  may  be  as  large  as  a  pin's  head  or  coalesce  into  masses  resembling 
curdled  milk.  They  may  be  seen  on  the  roof  of  the  mouth,  on  the 
soft  palate,  tonsils,  and  posterior  pharyngeal  wall.  If  the  affection 
is  progressive,  the  tongue  and  inner  surface  of  the  cheelcs  become 
coated  with  a  white,  closely  adherent  pellicle.  In  neglected  cases  the 
sprue  may  be  of  a  yellowish  color  if  sarcinse  are  present,  or  blackish 
or  grayish  in  hue  if  other  fungi  have  obtained  lodgement.  Consid- 
erable force  is  required  to  dislodge  the  growth  from  the  mucous  mem- 
brane, and  the  operation  will  cause  bleeding  and  considerable  pain 
and  traumatism. 

Occurrence. — Sprue  is  introduced  into  the  mouth  from  without. 
It  is  present  in  the  vaginal  secretions  of  the  mother,  and  has  been 
found  on  the  breast  nipple.  An  abrasion  of  the  mucous  membrane 
must  exist  in  order  that  the  fungus  may  obtain  lodgement.  It  is 
therefore  found  in  infants  whose  mouths  have  been  harshly  washed 
with  unclean  fingers  or  into  whose  mouths  unclean  breast  or  bottle 
nipples  have  been  introduced.  The  fungus  having  gained  access  to 
the  cement-substance  between  the  epithelial  cells,  proliferates  into 
the  deeper  layers  of  epithelium,  and  may  even  invade  the  underlying 
connective  tissue.  Sprue  carries  with  it  any  other  bacterial  flora 
which  may  be  present  in  the  mouth.  A  perfectly  normal  mucous 
membrane  is  invulnerable  to  sprue.  The  sprue  conidia  and  mycelia 
are  found  in  the  secretions  of  the  mouth  of  the  normal  baby.  Sprue 
is  seen  chiefly  in  infants  whose  health  is  below  the  average,  who  are 
inmates  of  institutions,  or  who  have  been  in  unhygienic  surroundings. 

Henoch  describes  cases  of  sprue  of  the  stomach.  This  is  admit- 
tedly rare,  and  occurs  in  the  form  of  slightly  prominent  plaques. 
Parrot  describes  sprue  of  the  gastric  mucous  membrane  as  not 
infrequent. 

Symptoms. — The  local  symptoms  are  due  to  the  presence  of  the 
growth.  In  mild  cases  the  patches  are  few  in  number  and  very 
minute.  In  neglected  cases  not  only  is  the  whole  mouth  the  seat  of 
the  disease,  but  also  evidences  of  infections  of  a  pyogenic  nature  occur 
in  the  form  of  erosions  of  the  buccal  mucous  membrane,  yellowish 
plaque-like  ulcerations  and  fissures  which  bleed  easily.     There  is  also 


478  DISEASES    OF    THE    MOUTH. 

dryness  of  the  mucous  membrane  which  has  not  been  attacked  or 
which  has  been  freed  from  the  fungus.  Sprue,  in  fact,  causes  dis- 
tinct reaction  of  the  healthy  mucous  membrane  in  the  vicinity  of  its 
invasion.  Infants,  even  in  the  early  stages,  suffer  from  mild  disturb- 
ances of  the  gastro-enteric  tract,  manifested  by  vomiting  and  greenish 
movements.  In  neglected  cases  marantic  symptoms  are  also  present. 
Older  writers  (Parrot)  believed  sprue  to  be  a  causal  factor  in  athrep- 
sia,  but  it  is  simply  a  complication. 

That  pain  is  felt  is  evinced  by  the  lack  of  desire  to  nurse.  A 
febrile  movement  occurs  if  the  intestinal  tract  is  involved. 

Treatment. — Prophylactic. — Everything  that  is  introduced  into 
the  mouth  of  the  infant  should  be  scrupulously  clean.  If  the  infant 
is  breast-fed,  the  breast  nipple  should  be  cleansed  before  and  after 
nursing  with  a  pledget  of  cotton  moistened  with  boric  acid  solution. 
The  infant's  mouth  should  not  be  cleansed  after  nursing.  In  cases  in 
which  the  roof  of  the  mouth  has  been  carelessly  cleansed  there  are  not 
only  the  aphthae  of  Bednar,  but  also  sprue  and  other  aphthae  in  the 
median  line  as  a  result  of  traumatism  to  Epstein's  pearls.  If  infants 
are  fed  artificially,  the  nipple  of  the  nursing-bottle  should  be  boiled 
in  soda  solution  once  daily.  If  these  precautions  are  carefully 
observed,  and  the  fingers  never  introduced  into  the  infant's  mouth, 
sprue  will  rarely  if  ever  occur.  The  normal  epithelium  and  normal 
secretions  are  safeguards  against  the  fungus. 

Curative. — The  growth  should  be  reimoved  by  cleansing  the  mouth 
gently  three  times  a  day  with  a  saturated  solution  of  boric  acid.  The 
utmost  gentleness  should  be  used.  Even  in  mild  cases  the  removal 
of  the  sprue  may  extend  over  a  number  of  days,  because  the  parasite 
quickly  reproduces  itself.  I  use  one  piece  of  absorbent  cotton  attached 
to  an  applicator  of  wood  or  a  tooth  pick  for  the  roof  of  the  mouth, 
another  for  the  tongue,  and  another  for  the  cheeks  and  lips.  If  it 
can  be  avoided,  the  mucous  membrane  should  not  be  caused  to  bleed. 
If  aphthae  exist,  they  should  be  touched  lightly  with  a  2  per  cent, 
solution  of  silver  nitrate.  The  bowels  should  be  opened  by  an  initia- 
tive mild  cathartic.  Everything  should  be  scupulously  clean.  The 
severe  cases,  in  which  there  is  a  septic  condition  due  to  extension  of 
the  sprue  to  the  gastro-enteric  tract,  occur  chiefly  in  foundling  asy- 
lums. The  infants  die  of  septic  infections.  In  private  practice  the 
prognosis  is  good  if  the  case  is  seen  early  and  correctly  treated. 
Baginsky  recommends  potassium  permanganate  (1 :  150)  ;  others  rec- 
ommend corrosive  sublimate  (1 :  2000),  or  formalin  (1-100)  (Holt), 
but  boric  acid  will  be  found  to  be  equally  satisfactory. 

Aphthous  Stomatitis  {Stomatitis  Aphthosa). — In  this  condition 
there  are  formed  on  the  soft  and  the  hard  palate,  the  mucous  mem- 
brane of  the  gums  and  tongue,  and  on  the  inner  surface  of  the  lips 


DISEASES    OF    THE    MOUTH.  479 

and  cheeks,  small,  round,  yellowish  superficial  ulcerations.  These 
ulcerations,  which  vary  in  form  and  number,  may  coalesce  and  form 
irregular  plaques.  It  is  a  question  whether  the  ulcerations  are  the 
rerbains  of  vesicles  which  have  burst,  thus  exposing  an  ulcerated  base, 
or  whether  they  are  primarily  ulcers.  I  am  inclined  to  the  former 
view,  for  in  the  so-called  herpetic  aphthae  of  the  tonsils  the  natural 
development  of  the  aphthous  ulcerations  can  be  observed  to  advance 
from  the  vesicular  to  the  ulcerative  stage.  This  condition  is  very 
common  in  infancy  and  childhood,  and  according  to  Monti  is  most 
frequent  between  the  first  and  the  third  year. 

Etiology.- — The  etiology  is  still  obscure.  Some  authors  consider 
aphthous  stomatitis  an  acute  infection  derived  from  the  gut,  possibly 
caused  by  toxins  generated  in  contaminated  milk  (Forcheimer,  Eitter, 
Kmeriem,  Schamtyr).  Others,  basing  their  opinion  on  bacteriolog- 
ical studies,  regard  it  as  a  purely  local  affection.  The  clinical  course 
of  the  disease  tends  to  support  the  former  view.  It  has  been  com- 
pared by  Forcheimer  and  others  to  the  so-called  foot-and-mouth  dis- 
ease of  cattle. 

The  condition  may  occur  idiopathically  or  may  complicate  intes- 
tinal infection,  the  exanthemata,  bronchitis,  tonsillitis,  and  pneumonia. 
Some  authors  believe  that  the  affection  may  be  communicated  to 
others  by  the  secretions  of  the  mouth. 

Bacteriology. — The  forms  of  bacteria  most  commonly  found  in  the 
ulcerations  are  the  various  streptococci  and  staphylococci  (Judas- 
sohn).  Bernabei  has  found  the  pneumobacillus  of  Friedlander.  As 
these  bacteria  are  present  in  the  normal  secretions  of  the  mouth,  it  is 
doubtful  whether  they  bear  a  causal  relation  to  the  condition. 

Symptoms. — These  aphthae  vary  from  the  size  of  a  pin's  head  to 
that  of  a  split  pea.  They  are  invariably  surrounded  by  an  areola 
of  inflamed  mucous  membrane.  The  outline  of  the  ulceration  may 
be  round  or  irregular;  as  a  rule  the  ulcerations  are  superficial.  At 
the  line  of  junction  of  the  teeth  and  gums  they  may  show  a  tendency 
to  bleed  if  touched.  There  is  considerable  pain,  with  salivation,  and 
in  young  infants  also  a  distinct  febrile  condition  and  green  diarrhoeal 
movements.  In  other  cases  there  may  be  an  accompanying  angina 
with  swelling  not  only  of  the  lymph-nodes  at  the  angle  of  the  jaw,  but 
also  of  those  underneath  the  jaw.  In  addition  there  are  loss  of  appe- 
tite, and  restlessness  at  night. 

Course.' — In  well-nourished  infants  and  children  the  tendency  is 
to  limitation  of  the  aphthae  and  spontaneous  recovery  within  three 
or  four  days.  In  marantic  or  badly  nourished  children  in  unhygienic 
surroundings,  the  aphthae  are  likely  to  spread,  the  ulcerations  pre- 
senting the  appearance  of  a  mixed  infection.     Such  cases  are  difficult 


480  DISEASES    OF    THE    MOUTH. 

to  control.  As  a  rule,  however,  the  disease  runs  its  course  without 
leaving  any  lasting  ill  results. 

Treatment. — The  treatment  of  the  cases  in  which  the  ulcerations 
or  aphthae  remain  discrete  and  in  which  mixed  infection  does  not 
occur  is  begun  with  a  saline  cathartic,  such  as  magnesia,  or  a  dose  of 
castor  oil.  The  mouth  should  not  be  washed.  '  Careless  attempts  to 
cleanse  the  mouth  are  likely  to  cause  the  aphthae  to  coalesce  and  spread, 
and  also  to  cause  intense  pain.  I  administer  a  small  dose  of  ferric 
chloride,  made  up  with  glycerin,  every  three  hours.  In  most  cases 
this  will  suffice.  The  use  of  potassium  chlorate  should  be  avoided 
with  infants.  If  the  edges  of  the  gums  adjacent  to  the  teeth  are 
affected,  the  teeth  should  be  gently  washed  three  times  daily  with  a 
weak  solution  of  tincture  of  myrrh  or  a  saturated  solution  of  boric 
acid.  If  the  aphthae  coalesce,  they  should  be  touched  once  daily  with 
a  2  per  cent,  solution  of  silver  nitrate.  With  intractable  young  chil- 
dren, care  should  be  taken  in  washing  the  mouth  not  to  traumatize  the 
unaffected  mucous  membrane. 

Toxic  Stomatitis. — I  have  seen  a  number  of  cases  of  stomatitis 
caused  by  irritant  poisons,  such  as  potash  and  ammonia.  The  chil- 
dren so  affected  had  attempted  to  drink  a  solution  of  potash  or 
ammonia  from  a  bottle  left  within  their  reach. 

Symptoms. — The  symptoms  were  purely  local.  The  mucous  mem- 
branes of  the  lips  had  a  characteristic  oedematous,  swollen,  and  trans- 
parent appearance,  the  buccal  mucous  membrane  and  the  tongue  were 
l^ale  and  oedematous,  and  the  papillae  were  erect  and  transparent. 

Treatment. — The  treatment  is  expectant.  A  mixture  containing 
bismuth  subcarbonate  seemed  to  give  most  relief.  On  subsidence  of 
the  oedema  the  mucous  membrane  presented  a  dry  appearance.  Some- 
times small  aphthous  ulcerations  appeared,  which  healed  under  appli- 
cations of  a  2  per  cent,  solution  of  silver  nitrate. 

In  one  case,  five  years  of  age,  symptoms  of  oesophageal  stricture 
were  present  three  months  after  the  ingestion  of  the  irritant.  Strict- 
ures of  the  oesophagus  are  more  common  after  the  ingestion  of  potash 
or  lye  solutions  than  after  corrosion  by  ammonia. 

Ulcerative  Stomatitis  {Stomatitis  ulcerosa;  Stomacacw ;  Ger., 
Mundfdule) . — Ulcerative  stomatitis  is  a  disease  of  the  mucous  mem- 
brane of  the  mouth,  g-ums,  and  tongue,  characterized  by  ulceration 
with  a  fetid  odor. 

Etiology. — The  etiology  is  still  obscure.  Friihwald  and  Bernheim 
found  bacilli  and  spirocha^tae  (spirilla)  in  the  ulcers.  The  fetid  odor 
of  the  breath  was  reproduced  in  the  cultures  of  Bernheim.  The 
bacillus  is  lanceolate  in  form  and  resembles  the  diphtheria  bacillus. 
These  bacilli  and  spirilla  are  probably  identical  with  those  described 
in  1896  by  Vincent  as  occurring  in  hospital  gangrene. 


DISEASES    OF    THE   MOUTH.  481 

Occurrence.^ — The  affection  is  most  common  between  the  fourth 
and  the  eighth  year.  The  period  of  infancy  seems  to  be  exempt,  in 
my  opinion,  because  of  the  absence  of  teeth.  It  occurs  in  children 
who  have  been  neglected  or  who  have  lived  in  unhygienic  surround- 
ings, and  is  therefore  very  common  in  patients  of  clinics  and  dis- 
pensaries. 

Symptoms. — In  the  milder  forms  there  is  a  line  of  yellowish  ulcer- 
ation along  the  margin  of  the  gums  at  the  point  of  contact  with  the 
teeth,  and  the  adjacent  mucous  membrane  is  red  and  inflamed. 
When  the  gums  are  touched  either  in  washing  or  in  examination, 
bleeding  readily  occurs.  There  is  a  fetid  odor  to  the  breath,  the 
tongue  is  coated;  some  children  have  pain  and  loss  of  appetite,  and 
a  slight  fever.  In  the  severer  cases  there  are  deep  ulcerations  along 
the  margins  of  the  gums,  which  bleed  on  the  slightest  provocation. 
Ulcers  with  a  greenish-yellowish  base  are  seen  along  the  border  of  the 
tongue  and  beneath  it.  In  these  cases  the  lymph-nodes  beneath  the 
body  of  the  jaw  are  enlarged  and  painful  as  a  result  of  the  infection. 
The  salivation,  pain,  and  local  disturbance  are  considerable,  and  the 
fetor  oris  is  marked.  The  buccal  mucous  membrane  at  the  points  of 
contact  with  the  teeth  may  be  deeply  ulcerated,  indurations  of  the 
tissues  of  the  adjacent  mucous  membrane  being  also  present.  Small 
particles  of  necrotic  tissue  are  seen  to  flow  away  in  the  saliva.  So 
great  is  the  pain  that  some  children  refuse  to  open  the  mouth  or  par- 
take of  food.  I  have  seen  the  teeth  become  loose  and  necrosis  of  the 
alveolar  process  result.  Under  the  latter  condition  there  is  much 
swelling  of  the  tissues  above  and  beneath  the  jaw  with  enlarged 
lymph-nodes.  The  tonsils  may  also  be  the  seat  of  ulceration  of  the 
same  character  as  that  occurring  at  the  lateral  margin  of  the  tongue. 

Treatment. — Cleanliness  is  the  first  step  toward  lessening  the 
intensity  of  the  inflammation.  The  mouth  is  washed  every  three 
hours  with  a  solution  of  potassium  chlorate,  made  by  adding  a  tea- 
spoonful  of  the  saturated  solution  to  a  small  glassful  of  water,  or 
with  a  0.5  per  cent,  solution  of  formalin.  Internally,  liberal  doses 
of  ferric  chloride,  made  up  with  glycerin  and  water,  have  given  the 
best  results.  If  there  are  extensive  ulcerative  processes  along  the 
gums,  the  line  of  ulceration  is  gently  touched,  once  a  day  with  a  10 
per  cent,  solution  of  silver  nitrate.  In  addition,  the  patient  must 
have  an  abundance  of  fresh  air,  and  is  given  a  nutritious  fluid  diet, 
with  fresh  fruits  and  a  small  allowance  of  wine. 

Gonorrhoeal  Infection  of  the  Mouth, — Gonorrhoeal  or  blennor- 
rhceal  stomatitis  is  an  infection  of  the  mucous  membrane  of  the  mouth 
by  the  gonococcus  of  IS'eisser.  Infection  occurs  only  in  places  where 
the  mucous  membrane  has  been  injured.  There  may  be  an  associated 
gonorrhoeal  infection  of  the  eyes  or  the  vulva  and  vagina.     The  infec- 

31 


482  DISEASES    OF    THE    MOVTH. 

tion  may  be  introduced  into  the  month  by  the  fingers  of  the  nurse  or 
mother.  If  the  mother  is  suffering  from  gonorrhoea,  infection  may 
occur  at  the  time  of  birth  or  subsequent  to  parturition.  The  cases 
thus  far  reported  (Rosinski,  Kast)  have  developed  from  two  to  thir- 
teen days  after  birth. 

Ssmiptoms. — The  constitutional  disturbance  is  slight  in  some  cases ; 
there  is  no  fever,  no  pain,  and  no  interference  with  suckling.  In 
other  cases  I  have  observed  depression  and  sepsis  with  a  mixed 
phlegmonous  infection  of  the  fauces,  inability  to  nurse,  and  asthenia 
with  death.  The  lesions  occur  on  those  parts  of  the  hard  palate  most 
likely  to  suffer  from  traumatism  and  subsequent  infection — the  parts 
favored  by  Bednar's  aphthae,  the  median  raphe  in  the  alveolar  proc- 
esses of  the  hard  palate,  and  the  anterior  two-thirds  of  the  tongue. 
Inspection  reveals  yellowish-white  patches,  due  to  infiltration  of  the 
superficial  epithelial  layers  of  the  mucous  membrane  with  inflamma- 
tory products.  There  is  no  pseudomembranous  formation,  but  a  pul- 
taceous  thickening.  There  is  little  tendency  to  spread,  and  no  inflam- 
matory reaction  of  the  adjacent  mucous  membrane.  The  discharge 
is  so  slight  that  the  saliva  remains  clear. 

Examination  of  the  secretion  from  the  patches  on  the  hard  palate 
(which  are  generally  symmetrical)  and  on  the  tongue  reveals  the 
presence  of  abundant  gonococci  not  only  on  the  surface,  but  also  in- 
vading the  mucous  membrane  along  the  cement-substance  between 
the  epithelial  cells.  The  infection  differs  from  that  seen  in  adults 
(Cutler),  in  whom  great  constitutional  disturbance  and  severe  inflam- 
mation of  the  whole  mucous  membrane  of  the  mouth  are  combined 
with  a  profuse  ichorous  buccal  discharge  and  with  pain.  Some  cases 
recover;  others,  as  mentioned  above,  develop  sepsis  and  asthenia 
and  die. 

Treatment. — The  treatment  is  limited  to  the  enforcement  of  strict 
cleanliness,  and  to  local  applications  of  weak  solutions  of  silver  nitrate 
(2  per  cent.).  The  mouth  may  be  washed  twice  daily  with  a  10  per 
cent,  solution  of  protargol  or  argyrol. 

Pseudodiphtheritic  Stomatitis. — This  form  of  stomatitis  was  first 
accurately  described  by  Epstein.  It  is  seen  in  newborn  infants  who 
have  sustained  a  traumatism  of  the  mucous  membrane  of  the  mouth. 
An  infection  of  the  injured  membrane  with  streptococci  results  in 
the  formation  of  a  membrane  resembling  that  seen  in  true  diphtheria. 
These  cases  occur  in  foundling-hospitals  and  amid  unhygienic  sur- 
roundings. 

Symptoms. — The  pseudomembrane  is  of  a  greenish-yellow  hue,  and 
may  spread  over  the  hard  and  soft  palate,  the  tongue,  and  the  pharynx. 
It  may  involve  secondarily  the  entrance  to  the  larynx,  as  happened 
in  the  cases  of  Epstein,  and  the  epiglottis  and  oesophagus  as  well. 


DISEASES    OF    TEE    MOUTH.  483 

Gastro-intestinal  symptoms  and  secondary  septic  pneumonia  are 
developed.  The  temperature  may,  as  in  other  cases  of  sepsis,  be 
normal,  or  even  subnormal.  As  a  rule,  the  lymph-nodes  are  not 
enlarged.  The  condition  must  be  differentiated  from  sprue  and 
aphthous  stomatitis.  Aphthous  stomatitis  does  not  show  any  pseudo- 
membrane;  microscopical  examination  will  aid  in  differentiating  this 
disease  from  sprue  and  gonorrhceal  stomatitis. 

Treatment. — Inasmuch  as  these  cases  are  of  sej)tic  origin,  their 
course  is  progressive.  On  the  other  hand,  small  patches  of  mem- 
brane may  be  limited  by  applications  of  a  10  per  cent,  solution  of 
silver  nitrate.  The  membrane  should  not  be  peeled  off,  nor  should 
the  mouth  be  cleansed  with  the  finger.  Antistreptococcic  serum  is 
of  no  use  in  these  cases. 

Noma  {Cancrum  Oris). — ISToma  is  a  specific  bacterial  infection 
which  attacks  the  tissues  of  one  or  both  sides  of  the  face,  resulting  in 
gangrene  and  destruction  of  the  soft  and  hard  parts.  Babes  and 
Zambolovici  differentiate  it  from  all  other  forms  of  gangrenous  sto- 
matitis and  gangrene,  such  as  those  described  by  Henoch  as  occurring 
on  the  vulva. 

Etiology. — The  etiology  is  still  obscure.  Investigations  thus  far 
tend  to  show  that  several  conditions  clinically  similar  have  been  found 
to  have  a  diverse  etiology.  Babes  and  Zambolovici  isolated  a  very 
minute  bacillus,  and  by  inoculation  experiments  in  animals  produced 
typical  noma.  They  found  that  this  bacillus  extends  through  the 
mucous  membrane  of  the  mouth,  especially  that  of  the  gums.  Accom- 
panying it  are  a  large  number  of  streptococci,  spirochgetse,  and  other 
bacilli.  The  latter  play  an  active  secondary  role  in  the  production 
of  the  gangrene.  Gangrene  is  caused  by  an  overwhelming  bacterial 
invasion  of  the  tissues.  The  toxins  produced  cause  death  of  cell-life 
and  necrosis  in  mass.  In  another  set  of  cases,  Walsh  found  the 
bacillus  of  diphtheria.  These  cases  would  appear  to  correspond  to 
those  published  by  Freimuth  and  Petruschky,  who  found  a  bacillus 
identical  with  the  diphtheria  bacillus  in  cases  of  noma  of  the  vulva. 

The  greater  number  of  cases  of  noma  occur  after  measles.  It 
may  follow  any  of  the  exanthemata,  typhus,  typhoid  fever,  or  any 
disease  through  which  the  power  of  resistance  to  infection  is  lessened. 

Symptoms. — Henoch  and  Baginsky  hold  that  in  many  cases  an 
ulcerative  stomatitis  has  preceded  the  main  affection.  The  disease 
begins  on  the  mucous  membrane  and  invades  the  cheeks  from  within. 
Henoch  alone  has  seen  it  begin  from  without  in  the  form  of  a  phleg- 
mon of  the  cheek.  It  is  first  seen  as  a  small  ulcer  with  a  blackish- 
gray  base  on  the  buccal  mucous  membrane  opposite  the  teeth,  or  it 
may  begin  as  a  vesicle  with  serosanguinolent  contents.  After  a 
period  of  time  varying  from  a  few  hours  to  three  or  seven  days  the 


484  DISEASES    OF    THE    MOUTH. 

tissues  of  the  cheeks  become  brawny  and  cedematous,  the  oedema 
involving  the  eyelids  and  lips.  A  dark,  livid  area  finally  appears 
on  the  corresponding  exterior  surface  of  the  cheek.  This  area  becomes 
black  and  gangrenous.  Perforation  and  spreading  of  the  gangrene 
rapidly  result.  The  jaw  may  necrose  and  the  teeth  fall  out.  The 
process  may  spread  downward  along  the  neck,  involving  the  shoulder 
in  an  oedematous,  emphysematous,  gangrenous  mass.  The  indura- 
tion of  the  tissues  of  the  cheek  occurring  in  many  forms  of  stomatitis 
ulcerosa  should  not  be  confounded  with  this  affection ;  in  these  forms 
of  induration  gangrene  is  absent.  In  all  cases  of  noma  a  marked 
gangrenous  odor  pervades  the  atmosphere  about  the  patient. 

The  general  condition  of  many  cases  is  astonishingly  good  at 
first.  The  children  seem  unconcerned,  and  sit  up  in  bed  and  play. 
The  patient  finally  succumbs  to  the  toxsemia  accompanying  such 
great  destruction  of  tissue.  There  may  be  a  febrile  movement  (103° 
to  104°  F.,  39.4°  to  40°  C).  The  swallowing  of  gangrenous  products 
in  some  cases  causes  a  prostrating  and  uncontrollable  diarrhoea  of  a 
septic  character.  There  is  little  or  no  pain.  Death  results  within 
two  or  three  weeks,  either  from  general  toxsemia  and  heart  failure  or 
complicating  pneumonia. 

Occurrence  and  Prognosis. — From  a  study  of  the  literature,  noma 
is  found  to  occur  most  frequently  between  the  second  and  the  seventh 
year.     The  mortality  is  very  high — fully  Y5  per  cent.  (Woronichin). 

Treatment. — The  most  diverse  methods  have  been  employed  in  an 
endeavor  to  arrest  the  progress  of  this  affection.  To  support  the 
strength  of  the  patient  is  the  first  consideration;  careful  ventilation, 
antiseptic  and  deodorizing  solutions  to  destroy  the  gangrenous  odor, 
good  food,  and  wine,  are  all  of  service. 

The  local  treatment  varies.  Some  authors  advise  dusting  iodo- 
form on  the  gangrenous  area ;  others  advocate  the  use  of  caustic  zinc 
pastes  in  order  to  determine  the  line  of  demarcation  between  the  gan- 
grenous and  healthy  tissues.  The  Paquelin  cautery  with  knife-blade 
attachment  has  been  employed  to  remove  the  gangrenous  tissue.  So- 
lutions of  boric  acid,  thymol,  and  salicylic  acid,  should  be  freely 
emjjloyed  to  keep  the  mouth  and  parts  clean. 

In  those  cases,  probably  a  distinct  group,  in  which  the  bacillus  of 
diphtheria  is  found,  diphtheria  antitoxin  should  be  injected  in  proper 
doses. 

DISEASES    OF    THE    TONGUE. 

Congenital  Anomalies  of  Size  (Macroglossia). — The  tongue  of 
some  infants  who  are  otherwise  normal  is  unusually  large  and  pro- 
trudes slightly  from  the  mouth,  but  is  of  normal  shape.  It  is  pointed, 
but  somewhat  thicker  in  the  middle  (Fig.  104).     As  the  infant  grows 


DISEASES    OF   THE    TONGUE. 


485 


older  this  anomaly  becomes  less  apparent.  In  extreme  cases  the 
tongue  protrudes  from  the  mouth  as  a  tumor  mass.  It  is  discolored 
• — generally  of  a  livid  hue — and  becomes  ulcerated,  especially  at  the 
line  of  the  teeth.  Infants  thus  affected  cannot  nurse,  and  the  tongue 
must  be  reduced  in  size  by  surgical  means.  This  congenital  enlarge- 
ment of  the  tongue  may  be  due  to  an  increase  either  of  the  connective 
or  muscular  tissues,  or  of  both.  In  other  cases  the  lymph-spaces  of 
part  or  the  vv^hole  of  the  organ  are  dilated — there  is  a  lymphangioma 
of  the  tongue. 

There  are  thus  tv\^o  forms  of  macroglossia-^the  one  is  called 
macroglossia  lymphatica  congenita,  the  other  macroglossia  congenita 
hypertrophica.     The  lymphatic  form  shows  for  the  most  part  a  gross 

Fig.  104. 


^^ 


^       ^ 


%. 


cr 


y 


l^'' 


Simple  macroglossia. 


hypertrophy  of  the  organ  and  more  rapid  grov^th,  combined  v\7ith  sec- 
ondary changes  in  the  lov^er  jaw  and  teeth.  The  surface  of  the 
tongue  is  changed  in  appearance  through  defects  of  the  epithelium 
and  the  results  of  inflammatory  processes.  The  papillae  are  enlarged, 
the  organ  is  bluish  red,  nodular,  not  changed  by  muscular  action  and 
can  be  compressed.  Speech  is  for  the  most  part  changed.  The 
tongue  in  the  hypertrophic  form  is  smooth,  the  surface  enlarged,  the 
growth  slow,  the  tongue  less  movable  than  normally  and  changed  by 
muscular  action.  It  cannot  be  compressed,  as  in  the  lymphatic  form, 
and  is  less  apt  to  become  inflamed.  The  surgical  procedures  have 
consisted  in  compression,  excision,  and  an  ignipuncture,  the  latter 
being  the  most  advisable  (Eras).  In  cretins  and  the  Mongolian 
forms  of  idiocy  the  tongue  is  also  enlarged.     It  is  broad,  thick  and 


486 


DISEASES    OF   TEE    TONGUE. 


flat,  and  protrudes  from  between  the  lips.  In  these  patients  the  con- 
dition calls  for  no  special  treatment. 

Ringworm  of  the  Tongue  (Wandering  Bash  of  the  Tongue; 
Lingua  Geographica). — Eingworm  of  the  tongue  is  a  common  affec- 
tion of  infants  and  children.  It  was  probably  first  described  by 
Santulus  in  1854.  Parrot  regarded  it  as  a  symptom  of  hereditary 
syphilis — a  view  which  has  no  clinical  support. 

In  103  cases  reported  by  Bohm,  the  condition  occurred  sometimes 
in  early  infancy,  sometimes  as  late  as  the  twelfth  year  of  life,  and 
was  most  frequent  between  the  first  and  the  second  year. 

Etiology. — The  etiology  is  obscure.  Bohm  believes  it  to  be  con- 
nected with  a  lymphatic  diathesis  (scrofulosis).  It  is  found  chiefly 
among  children  of  the  lower  classes.  It  may,  however,  be  seen  in 
children  in  good  hygienic  surroundings  and  who  are  otherwise  healthy. 


Fig.  105. 


Fig.  106. 


Ringworm    or   wandering   rash    of 
the  tongue,  lingua  geographica. 


Epithelial  desquamation  of  the 
tongue. 


If  scrapings  from  the  borders  of  the  patches  of  an  affected  tongue 
be  examined  microscopically  when  fresh,  large  numbers  of  zooglsea 
of  coccus  form,  in  some  cases  mingled  with  sarcina?,  will  be  seen. 
The  presence  of  the  latter  micro-organism  explains  the  yellow  color 
of  the  border  of  the  patches  in  some  cases.  The  disease  sometimes 
affects  several  children  of  a  family. 

Symptoms. — The  symptoms  are  limited  to  the  appearance  of  the 
patches  on  the  tongue.  At  the  tip,  but  most  frequently  at  the  sides 
of  the  tong-ue,  are  seen  areas  sharply  circumscribed  by  narrow,  sin- 
uous, perfectly  oval  or  round  borders  (Fig,  105).  The  border  is  not 
only  distinctly  raised  above  the  epithelium  of  the  tongue,  but  also 
is  of  limited  breadth  and  has  a  more  pronounced  whitish  or  yellow- 
white  color  than  the  rest  of  the  tongue.     Inside  this  border,  if  the 


DISEASES    OF    THE    TONGUE.  487 

patch  is  oval,  the  tongue  seems  to  be  denuded  of  its  epithelium  and 
is  reddish  in  color.  This  condition  should  be  differentiated  from 
desquamation  of  the  epithelium  on  the  dorsum  of  the  tongue,  which 
presents  a  similar  appearance,  but  in  which  the  patches  have  not  the 
band-like  border  (Fig.  106).  Children  do  not  appear  to  suffer  incon- 
venience from  this  condition  of  the  tongue. 

Treatment.- — Treatment  of  the  most  diverse  kinds,  including  local 
application  of  tincture  of  iodine  and  the  use  of  ferric  chloride,  has  in 
my  experience  failed  to  produce  results. 

Desquamation  of  the  Epithelium  of  the  Tongue.— In  this  con- 
dition, which  has  been  confounded  with  that  just  described,  there  are 
seen  areas  of  irregular  size  and  apparently  denuded  of  epithelium. 
The  boundary  of  these  areas  is  sharply  outlined,  but  the  epithelium 
bounding  the  areas  is  apparently  normal  (Fig.  106).  The  tongue 
looks  as  if  the  epithelium  had  been  scraped  off.  The  condition 
demands  no  treatment,  since  it  is  only  a  symptom  of  mild  derange- 
ment of  the  digestive  processes. 

Tongue-swallowing. — Tongue-swallowing  is  a  term  applied  to  a 
peculiar  phenomenon  seen  in  some  infants  who  are  the  subjects  of 
nasal  obstruction.  Infants  normally  breathe  through  the  nose  when 
at  rest,  the  tongue  being  in  contact  with  the  roof  of  the  mouth.  If 
nasal  breathing  is  obstructed  either  by  swelling  of  the  mucous  mem- 
brane or  by  deformity  of  bone,  or  adenoids,  the  infant  experiences 
great  difficulty  in  breathing  through  the  nose.  As  a  result,  not  being 
accustomed  to  keeping  the  mouth  open  and  the  tongue  on  the  floor  of 
the  mouth,  the  ineffectual  efforts  at  nasal  and  mouth-breathing  cause 
the  infant  to  draw  the  tongue  inward.  The  tip  of  the  organ  folds 
on  itself,,  and  may  be  drawn  backward  into  the  mouth  in  the  efforts 
at  mouth-breathing,  causing  a  peculiar  snapping  noise  to  be  heard  on 
inspiration. 

Treatment. — The  remedy  in  these  cases  is  nasal  douching,  and 
dilatation  of  the  nasal  passages  with  pledgets  of  cotton.  The  cotton 
is  rolled  around  a  probe  or  applicator,  moistened  with  castor  oil, 
introduced  once  a  day  into  the  nares,  and  allowed  to  remain  about 
five  minutes.     If  the  infant  has  adenoids  they  should  be  removed. 

Tongue-tie.— Tongue-tie  is  a  condition  for  the  relief  of  which  the 
physician  is  frequently  consulted.  Some  mothers  will  ascribe  ineffi- 
cient nursing  to  this  condition.  With  a  breast  secreting  sufficient 
milk  tongue-tie  would  not  prevent  nursing.  The  existence  of  the 
condition  is  readily  detected  if  the  organ  is  bifid  at  its  tip  when  pro- 
truded. The  frenulum  will  in  such  cases  be  seen  to  extend  to  the 
extreme  tip  of  the  tongue  in  a  fan-shaped  manner. 

Treatment. — The  frenulum  being  membranous  is  easily  divided. 
It  should  be  caught  in  the  bifid  groove  of  the  pocket-case  director 


488  DISEASES  OF  THE  (ESOPHAGUS. 

and  made  tense,  and  the  membranous  portion  divided  with  a  pair  of 
round-ended  scissors.  The  ends  of  the  scissors  should  be  directed 
to  the  floor  of  the  mouth.  There  is  little  bleeding.  The  infant 
should  be  placed  at  the  breast  directly  after  the  operation,  so  that  the 
act  of  suckling  maj  stop  the  hemorrhage. 

MALFORMATIONS   OF   THE   UVULA. 

The  uvula  is  often  bifid  in  infants.  This  condition  is  only  of 
anatomical  interest.  There  are  cases  in  which  the  uvula  is  relaxed 
and  elongated.  In  one  case,  in  a  boy  five  years  of  age,  the  uvula 
was  so  long  that  it  gave  rise  to  an  incessant  night-cough.  On  excision 
of  the  uvula  the  cough  ceased. 

DISEASES   OF    THE   (ESOPHAGUS. 

Congenital  Anomalies. — Branchial  Fistulse.^ — Among  the  congen- 
ital anomalies  connected  with  the  oesophagus  is  the  so-called  fistula 
colli  congenita.  This  is  due  to  a  faulty  closure  of  the  branchial  clefts 
in  foetal  life.  This  fistula  is  generally  unilateral,  and  is  found  at  the 
inner  side  of  the  sternomastoid  muscle.  It  may  be  bilateral.  It 
generally  leads  to  the  pharynx  or  oesophagus,  and  may  end  in  a  blind 
canal.  The  canal  may  discharge  mucus  containing  ciliated  epithe- 
lium and  leucocytes.  Hennes  described  a  cartilaginous  grovrth  in  the 
neck,  of  which  I  have  seen  an  instance.  It  occurs  in  the  same  situa- 
tion as  the  above  fistula,  and  is  traceable  to  the  same  faulty  closure 
of  the  branchial  clefts. 

Branchial  Cysts. — Branchial  cysts  are  cystic  tumors  of  the  neck 
and  some  parts  of  the  head,  originating  from  congenital  defects  of 
development.  The  primary  origin  of  these  tumors  corresponds  to  the 
location  of  one  of  the  branchial  clefts,  most  frequently  the  second 
and  third,  in  the  vicinity  of  the  larynx  and  pharynx.  They  are  in 
intimate  relation  with  the  sheaths  of  the  large  vessels  of  the  neck,  the 
jugular  vein,  and  carotid  artery.  The  cysts  are  classified,  according 
to  their  contents,  into  mucous,  atheromatous,  serous,  and  hematocysts. 
Branchial  cysts  are  of  rare  occurrence.  The  serous  variety  is  ob- 
served in  early  life,  either  congenital  or  develops  during  infancy  or 
childhood,  whereas  the  atheromatous  cysts  are  seen  in  early  adult  life. 
These  cysts  are  seen  most  frequently  on  the  left  side  of  the  neck. 
Their  further  consideration  and  treatment  is  of  a  surgical  nature. 

Diverticula  of  the  (Esophagus. — These  occur  in  childhood,  are  con- 
genital in  origin,  and  are  accompanied  by  symptoms  of  diSicult  deglu- 
tition of  solid  foods,  though  fluids  may  be  swallowed.  In  some  cases 
the  food  collects  in  the  diverticulum,  causing  swelling  of  the  neck, 


DISEASES  OF  TEE  CESOPHAGUS. 


489 


with  spells  of  coughing  and  consequent  emptying  of  the  diverticulum. 
With  the  difficulty  of  deglutition  there  is  regurgitation  of  the  food 
after  eating.  In  a  case  recorded  by  Kurz  there  were  undulatory 
movements  at  the  side  of  the  neck  and  gurgling  noises  heard  on  swal- 
lowing. A  sound  could  be  passed  into  the  stomach,  but  at  the  junc- 
tion of  the  upper  third  with  the  lower  two-thirds  of  the  oesophagus  the 
sound  passed  into  a  pocket.  In  this  case  food  could  be  caused  to  pass 
into  the  stomach  while  the  patient  was  placed  in  a  certain  position. 
In  an  interesting  case  described  by  Adams  the  diverticulum  commu- 
nicated with  the  trachea. 

Fig.  107. 


Congenital  branchial  cyst.     Infant  seven  months  of  age  (Dr.  Henry  Heiman's  case). 


The  above  diverticulum  may  be  primary,  of  the  congenital  variety ; 
or  secondary,  due  either  to  a  stricture  of  the  oesophagus  and  dilatation 
above  the  stricture,  or  to  traction  from  without  on  the  oesophagus  by  a 
caseous  lymph-node. 

Congenital  Stricture  of  the  CEsophagus. — Sneider  has  collected  15 
cases  of  congenital  stricture  of  the  oesophagus,  most  of  which  gave  no 
symptoms  during  infancy  and  childhood.  The  stricture  in  these  cases 
was  either  in  the  form  of  a  ring  of  tissue  or  folds  with  thickening  of 
the  mucosa.  They  were  present  either  in  the  upper  or  lower  part  of 
the  oesophagus.  Only  2  of  the  15  cases  died  during  childhood,  the 
symptoms  appearing  for  the  most  part  in  early  youth. 

The  case  recorded  by  Turner  was  that  of  a  child  eighteen  months 
old.  It  had  always  suffered  from  difficulty  in  swallowing,  and 
weighed  only  14|^  pounds.     The  mother  said  that  since  the  period  of 


490  DISEASES  OF  TEE  (ESOPEAGUS. 

weaning  the  child  had  become  emaciated,  and  the  difficulty  in  swal- 
lowing had  increased  so  that  finally  all  food  was  rejected.  A  sound 
having  the  diameter  of  the  small  finger  could  not  be  introduced  into 
the  stomach.  Postmortem,  the  stenosis  was  found  at  the  cardiac  end 
of  the  stomach  and  was  of  the  size  of  a  l^o.  2  catheter. 

Congenital  Atresia  or  A'bsence  of  the  (Esophagus. — The  oesophagus 
may  be  entirely  wanting,  and  in  such  cases  other  organs  show  anoma- 
lies ;  or  there  may  be  atresia  of  the  middle  third  of  the  oesophagus ; 
or  the  oesophagus  may  communicate  in  part  with  the  larger  bronchi. 
The  stomach  may  be  absent  in  some  of  these  cases.  In  such  cases 
the  infants  swallow,  choke,  have  cyanotic  attacks,  and  in  three  or  four 
days  cease  to  live.  In  one  case  published  by  Simon  the  oesophagus 
ran  circularly  around  the  trachea;  the  patient  survived  and  died  in 
adult  life. 

CEsophagitis. — Any  inflammation  of  the  mouth  or  the  pharynx 
may  extend  into  the  oesophagus,  such  as  croup,  diphtheria,  burns,  cor- 
rosions, sprue.  These  affections  cause  no  characteristic  symptoms 
apart  from  the  primary  disease. 

Caustic  (Esophagitis  (Traumatic  Stncture  of  the  (Esophagus). — 
This  is  caused  by  the  action  of  caustic  alkalies  or  mineral  acids  on 
the  tissues  of  the  oesophagus,  and  the  intensity  of  the  corrosion  varies 
with  the  amount  and  strength  of  the  caustic  taken  internally.  The 
caustic  alkalies,  such  as  potash  and  ammonia,  are  especially  likely  to 
be  swallowed  by  children.  The  effects  of  the  corroding  agent  are 
shown  first  externally.  If  a  concentrated  mineral  acid  has  been  taken, 
there  is  a  brown  or  a  black  eschar.  In  less  concentration  we  have 
white  or  grayish  eschars,  and  later  mild  inflammatory  reaction. 
Alkalies  cause  gelatinous  swelling  of  the  mucous  membranes  covering 
the  lips,  tongue,  and  buccal  cavity.  If  the  alkali  be  very  strong,  the 
tissues  are  converted  into  a  yellow  or  brownish  mass,  and  the  fatal 
issue  sets  in  before  any  reaction  takes  place.  If  the  agent  be  dilute, 
superficial  ulcers  form  after  the  primary  corrosion.  Reaction  sets 
in,  and,  following  the  inflammatory  stage  of  the  reaction,  cicatricial 
effects  result,  such  as  stricture. 

Symptoms. — The  symptoms  accompanying  the  swallowing  of  cor- 
rosive poisons  are  pain,  which  is  constant,  incessant  crying,  restless- 
ness, due  to  a  burning  sensation  in  the  mouth,  attended  with  great 
pain  and  difficulty  in  swallowing.  In  some  cases  blood  and  purulent 
matter  are  vomited.  There  is  great  thirst.  In  other  cases,  where 
the  concentration  of  the  alkali  has  not  been  great,  the  lips  are  swollen, 
the  mucous  membrane  of  the  mouth  presents  a  whitish,  gelatinous, 
swollen  appearance.  There  is  constant  salivation  ;  the  children  refuse 
to  take  solids  or  liquids,  inasmuch  as  the  least  attempt  at  swallowing 
causes  great  pain. 


DISEASES  OF  THE  (ESOPHAGUS.^  491 

Treatment. — The  treatment  of  these  cases  is  at  first  medical.  De- 
mulcents and  milk  are  given  in  large  quantities,  and  the  physician 
should  refrain  from  examinations  with  instruments  lest  perforation 
of  the  oesophagus  or  stomach  result.  After  a  few  weeks,  the  primary 
effects  of  the  corrosion  having  passed  off  and  cicatrization  of  the 
ulcers  having  taken  place,  a  stricture  of  the  cesophagus  results.  The 
treatment  of  this  stricture  is  surgical. 

Peri-oesophageal  Abscess  (Retro-oesophageal  Abscess). — Griffith 
has  reported  12  cases  of  this  affection.  It  is  not  infrequent  in  infancy 
and  childhood.  The  oesophagus  begins  above  at  the  seventh  cervical 
vertebra,  lying  in  front  of  the  spine.  It  passes  behind  the  right 
bronchus  between  the  two  pleural  sacs,  behind  the  pericardium,  and 
finally  passes  through  the  diaphragm.  Any  affection  of  the  spine, 
pleura,  pericardium,  or  lymph-nodes  at  the  root  of  the  lung  may  either 
cause  pressure  on  the  oesophagus,  involve  it  in  inflammation,  or,  if 
suppuration  exists,  the  pus  may  break  into  the  lumen  of  the  oesoph- 
agus. Cases  are  recorded  in  which  the  pressure  of  an  intubation 
tube  or  diphtheria  of  the  pharynx  has  involved  the  perioesophageal 
tissue  and  caused  abscess;  or  a  foreign  body  in  the  oesophagus  may 
cause  perforation  and  ulcer,  involving  the  adjacent  connective  tissue. 
If  a  foreign  body  is  lodged  in  the  cesophagus  and  is  contaminated,  as 
in  the  case  of  Soltmann,  with  actinomycosis,  abscess  of  the  oesophagus 
and  lung  may  result,  with  actinomycosis  of  the  latter  organ.  The 
most  frequent  cause,  however,  of  peri-  or  retro-oesophageal  abscess  is 
disease  of  the  vertebrae  of  a  tuberculous  nature. 

Symptoms. — These  will  vary  with  the  cause.  An  abscess  of  the 
pleura  or  a  lymph-node  pressing  on  the  oesophagus  will  give  symptoms 
of  oesophageal  stenosis.  In  some  cases  the  pressure  may  interfere 
not  only  with  deglutition  but  with  respiration,  and  give  rise  to  symp- 
toms resembling  laryngeal  stenosis,  necessitating  intubation.  As 
soon  as  the  tube,  however,  is  withdrawn  from  the  larynx,  the  dyspnoea 
returns.  The  larynx  may  also  be  pushed  to  one  side.  There  may 
be  temperature,  due  to  the  primary  disease.  In  one  of  my  own  cases 
there  were  spasmodic  attacks  of  coughing,  accompanied  by  cyanosis, 
and  in  one  of  the  attacks  a  discharge  of  pus.  The  source  of  the  pus 
in  this  case  was  probably  an  empyema  which  had  opened  into  the 
oesophagus.  These  attacks  were  repeated  at  intervals,  though  with 
less  expectoration  of  pus.     The  child  finally  made  a  good  recovery. 

In  spondylitis  there  will  be  symptoms  of  disease  of  the  vertebrse. 
If  perforation  occur  from  a  bronchus  or  caseous  gland,  there  are 
attacks  of  coughing,  vomiting  of  food  and  pus,  and  finally  symptoms 
resembling  putrid  bronchitis,  and  in  same  cases  lung  gangrene. 

Diagnosis.- — In  some  cases  the  diagnosis  is  not  only  difficult,  l)ut 
impossible.     If  the  cause  is  evident  and  the  abscess  can  be  reached 


492  DISEASES  OF  THE  (ESOPHAGUS. 

with  the  finger,  the  diagnosis  can  be  made ;  but  if  the  abscess  is  deep- 
seated,  beyond  the  reach  of  exploring  instruments,  the  disease  is  diag- 
nosed only  at  the  autopsy  table.  If  the  swallowing  of  a  foreign  body 
has  preceded  symptoms  which  resemble  retro-cesophageal  abscess,  an 
rc-ray  should  be  taken  to  locate  the  body. 

Prognosis, — The  prognosis  in  deep-seated  retro-oesophageal  abscess 
is  bad ;  that  in  spondylitis  likewise.  The  spontaneous  rupture  of  the 
abscess,  with  discharge  of  pus  externally  and  recovery,  is  exceptional. 
The  spontaneous  rupture  of  a  retro-oesophageal  abscess  may  result  in 
pus  finding  its  way  into  the  larynx,  thereby  causing  suft"ocation. 

Treatment. — The  treatment  of  retro-oesophageal  abscess,  if  diag- 
nosed promptly,  is  surgical.  It  may  be  stated,  however,  that  these 
abscesses  are  best  opened  from  without,  and  we  should  hesitate  to 
make  an  internal  incision  in  a  deep-seated  retro-oesophageal  abscess. 


SECTION  VII. 

DISEASES   OF  THE   STOMACH   AND   INTESTINES. 

Classification.- — The  classification  of  the  diseases  of  the  gastro- 
enteric tract  occurring  in  infancy  and  childhood  must  necessarily  be 
schematic  for  the  present,  for  much  is  yet  to  be  learned,  from  chem- 
ical, physiological,  and  pathological  standpoints,  concerning  some  of 
these  affections.  Any  classification,  therefore,  must  be  founded  on  a 
mixed  etiological  basis,  and  must,  of  necessity,  be  subject  to  future 
revision.     For  the  present  we  may  divide  these  diseases  into: 

i^*>s^.— Those  due  to  some  congenital  defect  in  the  constitution 
or  anatomical  construction  of  the  body. 

Second. — Those  v^^hich  are  due  to  some  fault  in  the  functional 
assimilation  of  the  food.  The  food  in  these  cases  is  free  from  bac- 
terial contamination  and  is  not  assimilated  and  the  infant  does  not 
thrive.  There  is  no  pathological  lesion  in  these  cases.  In  this  class 
belong  the  acute  dyspepsias,  both  of  the  stomach  and  intestines, 
various  forms  of  vomiting,  colic  and  tympanites,  all  leading  to  the 
main  result,  an  atrophy  or  marasmus. 

Third. — Those  disturbances  due  to  infection.  Bacteria  and  their 
toxins  are  the  agents  by  which  these  diseases  are  brought  about. 
In  this  class  belongs  the  acute  gastro-enteric  infections,  including 
cholera  infantum.  In  these  diseases  the  anatomical  lesion,  if  any 
exists,  is  in  the  majority  of  cases  only  temporary,  for  the  patients 
recover.  In  the  fatal  cases  the  anatomical  lesions  are  very  slight  and 
disproportionate  to  the  severity  of  the  disease,  being  due,  it  is  at  pres- 
ent supposed,  to  the  direct  action  of  the  bacteria  and  their  toxins  on 
the  superficial  structures  of  the  stomach  and  gut. 

Fourth. — Those  diseases  which  are  due  to  the  direct  action  of  the 
bacteria  themselves,  which,  in  addition  to  causing  constitutional  symp- 
toms, due  to  the  passage  of  the  toxins  into  the  circulation,  also  cause 
serious  anatomical  changes  in  the  tissues  of  the  gut,  some  of  these 
changes  causing  eventually  the  death  of  the  patient.  In  this  class  we 
would  place  dysentery  of  infancy  and  childhood,  and  the  various 
forms  of  ileocolitis,  which  have,  as  yet,  no  firm  etiological  basis  estab- 
lished by  investigation  and  experiment. 

Fifth. — A  series  of  diseases  caused  by  some  anatomical  condition 
or  neurosis.  In  this  class  must  be  placed  the  forms  of  congenital 
stenosis  of  the  pylorus,  dilatation  of  the  stomach,  which,  though  pri- 
marily caused  by  dyspeptic  disturbances,  eventually  supervenes  as  the 

493 


494  DISEASES    OF    THE   STOMACH  AND   INTESTINES. 

result  of  anatomical  weakness  of  the  muscular  structures  of  the 
stomach.  In  this  class  we  would  place  the  various  forms  of  consti- 
pation dejDending  upon  congenital  dilatation  of  the  colon. 

The  Stomach, — ^Anatomy. — The  oesophagus  enters  the  diaphragm 
at  about  the  level  of  the  ninth  dorsal  vertebra  ;  the  cardia  is  on  a  level 
with  the  tenth  dorsal  vertebra ;  the  pylorus  is  in  the  majority  of  cases 
situated  in  the  median  line,  but  in  some  cases  is  slightly  to  the  right 
of  it.  It  is  midway  between  the  tip  of  the  xiphoid  cartilage  and  the 
umbilicus,  and,  being  behind  the  liver,  is  not  normally  palpable. 
The  stomach  lies  in  an  oblique  position,  passing  from  behind  forward 
and  downward.  The  pylorus  is  from  two  to  two  and  one-half  bodies 
of  a  vertebra  lower  than  the  cardia.  In  the  newborn  infant  the  infe- 
rior portion  of  the  stomach  has  a  fundus  form  (Pfaundler),  which 
later  becomes  more  marked.  Occasionally  there  is  no  fundus,  and 
the  stomach  is  then  of  cylindrical  shape.  Between  the  time  of  birth 
and  the  seventh  month  the  fundus  of  the  stomach  increases  to  fully 
twice  its  original  length  (Pfaundler), 

Capacity. — The  capacity  of  the  stomach  is  still  a  matter  of  specu- 
lation. The  absolute  capacity,  as  given  by  Fleischman,  Drewitz, 
Pfaundler,  Holt,  and  Eotch,  varies  vdth  the  method  employed  to 
determine  it.  The  work  thus  far  done  has  been  carried  out  on  the 
cadaver,  and,  moreover,  the  methods  employed  presuppose  an  amount 
of  pressure  (14  c.c.  to  30  c.c.)  of  water  which  does  not  exist  in  the 
normal  state  during  life.  The  stomach  contracts  after  death  (sys- 
tole) ;  the  distention  with  air  or  fluids  is  thus  partly  artificial.  Lastly, 
the  stomach  capacity  is  of  little  aid  in  determining  the  point  at  issue 
- — the  quantity  of  food  which  should  be  taken  by  a  healthy  infant 
at  each  feeding.  Figures  giving  absolute  stomach  capacity  are  useful 
only  as  indicating  the  actual  size  of  the  organ  when  full  of  fluid,  a 
condition  rarely  present  during  life. 

In  the  following  table  (p.  495)  Plaundler's  results  are  compared 
with  those  of  others.  They  were  obtained  by  postmortem  distention 
with  fluid  at  a  pressure  of  30  c.c.  of  water.  Fleischman  distended 
the  stomach  at  14  c.c.  of  water  pressure. 

Function  and  Motility. ^ — The  stomach  of  breast-fed  infants  empties 
itself  in  two  hours  after  the  ingestion  of  a  full  nursing.  If  the 
quantity  of  milk  taken  is  small,  a  shorter  time  suffices.  Bottle-fed 
infants  taking  cows'  milk  need  fully  three  hours  to  accomplish  the 
same  result.  These  facts  teach  that  intervals  of  rest  between  the 
nursings,  and  a  rest  of  four  or  five  hours  once  in  twenty-four  honrs, 
are  necessary. 

Marking  out  the  Stomach  by  Percussion. — This  procedure  is  diffi- 
cult with  infants  and  children.  The  normal  stomach  is  rarely  found 
outside  of  the  left  hypochondrinm.     The  liver  fully  covers  the  stomach 


DISEASES   OF    TEE   STOMACH  AND   INTESTINES.  495 

in  the  collapsed  state.  In  the  recumbent  posture  the  stomach  may 
be  mapped  out  on  the  anterior  abdominal  parietes.  It  comes  forward 
in  the  triangle  formed  on  one  side  by  the  border  of  the  left  lobe  of  the 
liver  and  on  the  other  by  the  border  of  the  ribs.  Above,  the  apex 
of  the  triangle  is  formed  by  a  junction  of  the  ribs  and  the  left  lobe 
of  the  liver.  Below,  the  base  of  the  triangle  is  of  variable  length. 
In  the  axillary  line  the  fundus  in  a  moderately  distended  state  is  in 
contact  with  the  thoracic  walls,  between  the  liver  above  and  the  spleen 
below.  Above,  it  is  separated. from  the  lung  resonance  by  a  strip  of 
dulness  (the  left  lobe  of  the  liver)  which  changes  position  with  the 
movements  of  the  diaphragm.  The  tympanitic  resonance  reaches 
downward  in  a  vertical  direction  from  the  sixth  to  the  eighth  rib. 
Behind  this,  tympany  is  limited  by  the  posterior  axillary  line;  in 

Fleisch-    Drewitz. 

MAN 

c.c.  c.c. 

At  birth 30 

One  week      45 

One  month 77  99 

Two  months 79  215 

Tliree  months      140  130 

Four  months 165 

Five  months 290  253 

Six  months 260  297 

Seven  months       .    .  217 

Eight  months 289 

Nine  months .    .  510 

Ten  months 375  350 

Eleven  months 535 

Twelve  months ,    .  500 

One  to  two  years      220  588 

front,  by  the  triangle  above  referred  to.  I  have  frequently  been  able 
to  confirm  these  statements  of  Fleischman.  Anteriorly,  I  have  with 
the  aid  of  a  gastrodiaphane  shown  that  the  transverse  colon  passes  in 
front  of  the  stomach  just  beneath  the  liver.  It  should  be  remem- 
bered that  tympanitic  resonance  in  the  epigastrium  is  not  always  due 
to  the  stomach. 

Acids  of  the  Stomach. — When  digestion  is  not  in  progress  the 
stomach  contains  a  tenacious,  colorless  mucus,  neutra,l  in  reaction. 
When  food  is  in  the  stomach,  the  reaction  is  acid. 

Hydrochloric  acid  is  normally  present  in  the  stomach  of  the  infant 
(Leo,  Van  Puteren,  Wohlman)  ;  lactic  acid  only  occasionally.  Heub- 
ner  found  0.16  to  0.2  pro  mille  of  lactic  acid  present.  A  considerable 
amount  of  hydrochloric  acid  unites  with  the  salts  and  albumin  of  the 
milk,  and  is  found  as  combined  hydrochloric  acid.  When  combina- 
tion is  no  longer  possible, ,  the  residue  appears  as  free  hydrochloric 
acid.  The  amount  of  free  hydrochloric  acid  depends  on  the  quantity 
of  milk  ingested,  and  varies  from  0.8  to  2.1  pro  mille.     I  have  fre- 


Pfaund- 

ROTCH. 

Holt. 

LER. 

cc. 

C.C. 

c.c. 

30 

30 

36 

150 

75 

60 

175 

96 

99 

200 

100 

135 

230 

107 

150 

260 

108 

170 

295 

,  . 

264 

330 

365 

406 

445 

485 

243 

515 

640 

496  DISEASES    OF    THE   STOMACH  AND   INTESTINES. 

quentlv  failed  to  find  free  HCl  in  the  stomach  contents  of  infants  wlio 
are  fed  irregularly  at  frequent  intervals.  In  healthy  breast-fed  in- 
fants free  hydrochloric  acid  is  found  in  from  one  and  a  quarter  to 
two  hours,  and  in  bottle-fed  infants  in  from  two  to  two  and  a  half 
hours  after  nursing.  The  effect  of  the  lab-enzyme  on  the  milk  is 
marked  in  breast-fed  as  compared  with  that  in  bottle-fed  infants.  In 
the  former  the  action  of  the  acid  delays  that  of  the  lab-ferment,  while 
in  the  latter  coagulation  of  the  casein  occurs  in  a  short  time  and  in 
large  flocculi.  The  difference  in  retarding  the  action  of  the  lab- 
ferment  is  due  to  the  increased  alkalescence  of  mother's  milk,  which 
requires  more  acid  to  neutralize  the  alkali,  and  thus  to  render  coagu- 
lation possible :  hence  the  greater  digestibility  of  mother's  milk. 

Gastric  contents  containing  free  hydrochloric  acid  are  bacteri- 
cidal, while  combined  hydrochloric  acid  has  no  such  properties. 

Stomach  Digestion. — Stomach  digestion  in  the  infant  divides  itself 
into  three  periods :  The  first,  in  which  the  milk  is  split  by  the  lab- 
ferment  into  casein  coagulum  and  soluble  albumin;  the  second,  in 
which  the  stomach  contents  become  acid,  having  been  previously 
neutral  or  alkaline,  and  in  which  chlorine  combinations  are  entered 
into  by  the  casein  and  lactic  acid  is  formed;  and  third,  in  which  the 
above  phase  of  stomach  digestion  is  completed,  the  contents  pass  into 
the  gut  and  free  hydrochloric  acid  appears. 

Lobb-feniwnt. — Digestion  is  thus  accomplished  by  a  soluble  fer- 
ment, so-called  lab-ferment  or  pexin,  which  coagulates  the  casein  of 
the  milk;  a  soluble  ferment,  pepsin,  which  partly  dissolves  and  pep- 
tonizes this  coagulum;  and  chlorine  combinations  (HCl),  which  unite 
the  partially  peptonized  casein,  and  toward  the  end  of  digestion  pro- 
duce free  hydrochloric  acid.  Thus  the  principal  changes  in  the  milk, 
so  far  as  the  stomach  is  concerned,  occur  in  connection  with  the  casein.. 
As  soon  as  the  milk  enters  the  stomach,  it  is  coagulated  by  the  lab- 
ferment,  whether  its  reaction  is  neutral,  alkaline,  or  acid.  This 
casein  coagulation  depends  upon  the  lab  and  not  upon  the  acid  reac- 
tion of  the  stomach  juice.  Lab-ferment  is  present  in  the  infant's 
stomach  as  such,  and  can  be  demonstrated  in  the  stomach  of  prema- 
ture and  sick  infants.  Lab-coagulation  of  the  casein  is  accomplished, 
according  to  Duclaux,  in  about  fifteen  minutes.  Part  of  the  casein 
coagulum  is  acted  on  by  the  pepsin  and  chlorine  combinations  and  is 
converted  into  absorbable  peptones  (casease  or  caseon),  the  remainder 
passes  into  the  intestine,  where  digestion  is  completed  by  the  pan- 
creatic ferments. 

The  casein  coagulum  of  cows'  and  of  human-breast  milk  are  essen- 
tially different,  the  former  being  a  firm  mass,  containing  in  its 
meshes  the  fat  of  the  milk ;  the  latter  being  in  fine  flocculi  with  little 
of  the  fat  of  the  milk,  and  easily  acted  on  by  the  stomach  j  uices.     In 


DISEASES   OF    THE   STOMACH   AND   INTESTINES.  497 

the  bottle-fed  infant  the  stomach,  half  an  hour  after  feeding,  still 
contains  large  coagula,  whereas  at  this  time  the  breast-fed  infant's 
stomach  contents  consist  of  an  easily  absorbable  homogeneous  mass. 
Liquefaction  is  the  work  of  the  pepsin,  which  is  present  in  the  stomach 
juices  of  the  newborn  infant,  though  throughout  infancy  its  action  is 
weak  and  only  sufficient  to  act  on  the  proteids  of  the  milk.  Thus, 
half  an  hour  after  feeding,  albumoses  and  peptones  are  found  in  the 
stomach  both  of  breast-fed  and  bottle-fed  infants. 

Milk  Sugar. — Milk  sugar  is  split  partly  into  lactic  acid  about 
fifteen  minutes  after  feeding,  and  by  the  action  of  lactase  (Marfan) 
into  giycose  and  galactose.  This  view,  however,  is  not  accepted  by 
all  observers,  lactic  acid  not  being  admitted  as  normal  to  the  stomach. 
The  salts  of  the  milk  which  have  not  been  precipitated  are  directly 
absorbed.  The  fats  enter,  with  the  casein  coagula,  into  the  gut  almost 
entirely  unchanged,  or  a  fractional  part  is  saponified  by  lipase  (Mar- 
fan) and  absorbed  in  the  stomach. 

In  general,  it  may  be  stated  that  in  breast-fed  infants  digestion  is 
completed  in  one  and  one-half  to  two  hours ;  in  artificially  fed  infants 
taking  boiled  milk  in  two  and  one-half  to  three  hours,  and  in  four 
hours  in  those  taking  raw  milk. 

Bacterial  Flora. — The  bacterial  flora  of  the  infant  stomach  are  as 
yet  not  fully  investigated.  So  far  as  known  the  stomach  may  con- 
tain the  Bacterium  coli  commune,  the  Bacterium  lactis  aerogenes,  the 
Bacillus  subtilis  and  the  related  species,  Tyrothrix  granulatus  and 
Bacillus  butyricus  of  Hueppe,  the  Bacillus  pyocyaneus,  the  Bac- 
terium lactis  aerogenes,  the  Bacillus  megatherium,  the  Spirillum 
rugula,  a  leptothrix.  Staphylococcus  pyogenes,  Sarcina  ventriculi, 
oidium,  hay  bacillus,  and  mould  fungi. 

Intestinal  Digestion. — The  stomach  content  of  the  infant  as  it  is 
passed  into  the  intestine  consists  of  unabsorbed  water;  proteids 
which  are  made  up  of  casein  coagula  and  in  part  of  syntonin;  albu- 
moses and  peptones  in  combination  with  chlorides  and  ammonia ;  the 
fatty  acids,  leucin,  tyrosin ;  and  finally  gases,  especially  carbon  diox- 
ide. There  are  present  also  the  unabsorbed  portion  of  milk  sugar 
and  a  small  quantity  of  lactic  acid.  The  fats  pass  into  the  intestine 
for  the  most  part  suspended  in  the  watery  elements  of  the  milk  or 
entrapped  in  the  meshes  of  the  casein  coagula.  The  whole  stomach 
content  has,  as  it  passes  into  the  intestine,  an  acid  reaction,  more 
marked  in  the  artificially  fed  than  in  the  breast-fed  infant. 

The  intestinal  secretions  concerned  in  the  digestion  of  the  above 
stomach  content  are  those  of  the  pancreas,  liver,  and  intestinal  wall 
(follicles  of  Lieberklihn  and  Brunner's  glands). 

Pancreas. — This  organ  is  developed  at  birth,  has  a  weight  of  32 
grammes  or   1   ounce,   and  is,  therefore,   compared  with  the  body- 
32 


498  DISEASES    OF    THE   STOMACH  AND   INTESTINES. 

weight,  much  larger  than  iu  the  adult.  Whereas  in  the  infant  the 
pancreas  weighs  %oo,  in  the  adult  it  is  %oo  of  the  body-weight. 

Ferments. — In  the  adult  pancreatic  juice  there  are  three  fer- 
ments— trypsin,  ptyalin,  and  a  fat-emulsifying  ferment,  steapsin. 
The  infant's  pancreatic  secretion  reveals  trypsin  and  steapsin  at  birth, 
and  even  in  the  foetal  state.  These  ferments  are  present  in  small, 
but  for  the  infant's  uses  sufficient,  amounts.  There  is  still  a  differ- 
ence of  opinion  as  to  whether  ptyalin  is  present  at  all  in  the  pancreatic 
juice  of  the  newborn.  According  to  Karowin,  a  saccharifying  power 
can  be  detected  in  the  pancreatic  juice  not  earlier  than  the  sixth 
month  of  infancy,  whereas  Moro  has  found  traces  of  such  a  ferment 
in  the  pancreas  at  birth.  The  fact  of  its  absence  or  presence  in  but 
small  quantity  at  birth  has  been  brought  forward  as  an  argument 
against  the  use  of  amylacea  in  the  food  of  the  artificially  fed  infant 
at  this  age. 

Liver.- — The  formation  of  bile  begins  at  the  third  month  of  foetal 
life,  and  at  birth  both  bile  and  glycogen  are  found  to  be  formed  by 
the  liver.  The  bile,  which  in  quantity  is  comparatively  greater  at 
birth  than  in  the  adult,  contains  cholesterin,  fats,  lecithin,  mineral 
salts,  excepting  iron.  It  contains  small  quantities  of  taurocholic 
acid,  and  but  little  or  no  glycocholic  acid.  It  is  not  strongly  anti- 
fermentative  at  this  time.  It  contains  bilirubin  and  biliverdin,  and 
in  the  young  infant  urea.  Its  function  in  digestion  seems  to  be 
limited  to  aiding  emulsification  of  the  fats. 

Secretions  of  the  Intestinal  Walls. — The  intestinal  juices  secreted 
by  the  follicles  of  Lieberkiihn  and  the  glands  of  Brunner  are  alkaline 
in  reaction,  and  in  the  foetus  and  newborn  the  ferments,  present  in 
these  juices  in  the  adult,  seem  to  be  absent  (Miura).  The  role 
played  by  these  juices  in  digestion  is  still  a  subject  for  study. 

Digestion, — The  principal  process  taking  place  in  intestinal  diges- 
tion of  the  infant  is  the  transformation  of  the  casein  of  the  milk  by 
the  trypsin  of  the  pancreatic  juice  into  peptone  and  hemipeptone. 
Part  of  the  casein  is  rapidly  changed  into  joeptone  by  the  pancreatic 
juice,  whereas  the  other  portion  is  acted  upon  at  gTeat  length,  and 
from  hemipeptone  changed  into  absorbable  substances  which,  partly 
crystalline,  are  taken  up  by  the  mucous  membrane  of  the  gut  and 
synthetically  transformed  into  albumins. 

In  the  breast-fed  infant  the  casein  flocculi  are  digested  and  dis- 
solved in  the  duodenum,  and  the  contents  of  this  portion  of  the  gut 
are  slightly  acid.  In  bottle-fed  infants  the  digestion  and  solution  of 
the  casein  is  less  complete  in  the  duodenum  than  in  the  breast-fed 
infant,  and  the  reaction  of  the  contents  of  this  portion  of  the  intestine 
is  distinctly  acid. 

Milk  Sugar. — The  milk  sugar  is  split  in  the  gut  into  galactase 


DISEASES   OF    THE   STOMACH  AND   INTESTINES.  499 

and  dextrose  and  thus  absorbed.     This  is  accomplished,  according  to 
Marfan,  by  the  lactase  of  the  intestinal  juices. 

Fats. — The  fats  of  the  milk  pass  from  the  stomach  into  the  duo: 
denum  but  little  changed.  They  are  suspended  in  the  watery  element 
of  the  milk  or  entrapped  in  the  meshes  of  the  casein  flocculi  or  coagula. 
The  fats  are  partly  emulsified  and  in  part  split  up  by  the  pancreatic 
juice  into  fatty  acids  and  glycerin,  and  in  these  forms  absorbed  by 
the  intestinal  villi.  The  digestion  and  absorption  of  the  fats,  how- 
ever, is  incomplete  in  the  intestine  of  the  infant,  and  much  of  it  is 
excreted  in  the  fseces  in  the  form  of  neutral  fats  and  fatty  acids. 

In  the  healthy  breast-fed  infant  most  of  the  above  digestive  trans- 
formation is  completed  in  the  duodenum  and  the  products  are  absorbed 
in  the  upper  part  of  the  small  intestine.  This  is  especially  true  of 
the  casein  or  proteids,  of  which  only  traces  are  found  in  the  lower 
portion  of  the  small  intestine. 

Intestinal  Residue. — After  the  absorption  of  the  nutritive  portion 
of  the  intestinal  mess,  the  contents  of  the  intestine  consist  of  biliary 
remains,  amido-acids,  various  products  of  bacterial  fermentation, 
acids,  and  soaps,  which  are  in  part  taken  up  and  transformed  by  the 
liver  and  in  part  excreted.  In  addition,  there  are  neutral  fats  and 
fatty  acids.  The  minute  quantity  of  proteids  which  has  escaped 
digestion  and  solution  and  has  not  been  absorbed  is  transformed  by 
the  bacterial  flora  of  the  gut  into  the  products  of  decomposition,  and 
as  such  are  found  as  indol,  skatol,  phenols,  and  ammonia  in  the  faeces. 
These  also  are  in  part  taken  up  by  the  liver  and  in  part  excreted. 
The  processes  of  decomposition,  which  are  quite  limited  in  the  breast- 
fed and  marked  in  the  artificially  fed  infant,  reach  their  highest 
development  in  the  colon. 

Characteristics  of  the  Stools  of  Normal  Infants. — It  may  be 
stated  that  the  movements  of  bottle-fed  differ  from  those  of  breast-fed 
infants  in  that  they  are  lighter  in  color  and  in  the  main  more  bulky. 
In  the  perfectly  normal  breast-fed  infant  the  stools  may  at  times  vary 
in  color  and  general  consistence ;  thus  we  can  scarcely  speak  of  a 
uniformly  normal  movement.  Gregor  has  accounted  for  this  by 
assuming  that  the  stool  of  the  infant  at  the  breast  may  vary  because 
of  the  composition  of  the  breast-milk  from  day  to  day  and  at  different 
hours  of  the  day.  Inasmuch  as  the  percentage  of  fat  in  breast  milk 
varies  so  widely,  the  appearance  of  the  stool  will  vary  likewise.  In- 
fants fed  on  cows'  milk  and  carbohydrates  will  have  movements  resem- 
bling those  of  breast-fed  infants. 

If  a  number  of  normal  infants  are  observed,  it  will  be  seen  that 
from  time  to  time  even  the  breast-fed  infant  will  present  movements 
the  consistence  of  which  is  more  or  less  watery,  and  which  contain 
coarse  white  curds  and  particles  without  any  disturbance  of  the  func- 


500  DISEASES    OF    THE   STOMACH  AND   INTESTINES. 

tions  of  the  gut.  Moreover,  the  amount  of  water  contained  in  a 
normal  movement  is  considerably  more  so  tlian  would  appear  from 
its  ordinary  putty-like  consistence  on  the  diaper  (Czerny).  Infants 
taking  a  malted  food  will  present  movements  that  are  dry  and  broken 
up  into  crumbs,  and  which  have  a  distinct  odor  of  malt.  The  move- 
ment of  breast-fed  babies  and  those  fed  upon  carbohydrates  and  fatty 
food  are  softer  than  those  of  babies  fed  upon  cows'  milk  exclusively. 
The  movements  of  infants  fed  on  cows'  milk  exclusively  are  lighter 
in  color  than  those  of  the  breast-fed  child. 

In  general  the  faeces  of  infants  may  be  said  to  contain  digested 
absorbable  substances,  undigestible  substances,  digested  products  of 
digestion  and  decomposition,  anatomical  elements  of  the  digestive 
organs  of  the  stomach  and  gut,  mucus  elements,  and  bacteria.  If 
the  movements  of  the  breast-fed  infants  are  closely  examined,  they 
are  found  to  contain  small  whitish  curd  particles,  the  milk  granules 
of  Uffelmann.  These  were  at  first  thought  to  be  composed  of  casein : 
it  is  now  known  that  they  are  made  up  of  fat-crystals,  and  zoogloea 
of  bacteria.  '  Talbot  has  lately  demonstrated  that,  in  addition  to  fat 
and  soap  crystals,  these  curds  contain  nitrogen.  In  addition,  there 
are  found  in  the  fffices  of  infants  epithelial  elements,  bilirubin  crys- 
tals, and  cholesterin  plates.  Fat  appears  in  the  faeces  of  infants 
rarely  as  fat  crystals,  but  generally  as  fatty  acids,  neutral  fats,  and 
soaps. 

The  movements  of  infants  fed  on  a  mixed  diet  contain  free  starch- 
granules,  cellulose,  and  also  cholesterin  plates  and  bilirubin;  the  prod- 
ucts of  decomposition — indol,  skatol,  and  phenol — are  also  found, 
according  to  the  time  which  has  elapsed  since  the  voidance  of  the 
movements  (Blauberg).  Sugar  is  not  found  in  the  fseces  of  infants, 
or  only  in  small  quantities  (Uffelmann  and  Blauberg).  Michael  has 
found  that  the  gross  weight  of  faeces  in  the  newborn  breast-fed  infant 
was  about  1.5  per  cent,  of  the  gross  amount  of  food  ingested;  while 
later  in  infanc}'-  the  movements  were  2.7  per  cent,  of  the  amount  of 
food  ingested.  Rubner  and  Heubner  found  that  in  bottle-fed  infants 
fhe  fsEces  were  about  4.7  per  cent,  of  the  amount  of  food  ingested. 
Michael  found  that  the  faeces  in  the  first  days  of  infant  life  contained 
about  72  per  cent,  of  water,  while  in  the  ninth  month  of  infancy  they 
contained  85  per  cent. 

Reaction  of  the  Stools. — The  reaction  of  the  stools  of  infants,  both 
breast-  and  bottle-fed,  has  been  the  subject  of  much  discussion,  because 
of  the  difference  of  opinion  among  investigators  as  to  what  constitutes 
a  normal  movement  in  an  infant.  It  may  be  stated,  however,  that 
the  stool  of  the  breast-fed  infant  is  regularly  acid  in  reaction  and  has 
an  acid  odor  even  after  being  passed  for  some  time.  The  infant  fed 
upon  cows'  milk  has  a  stool  which  is  alkaline  in  reaction,  sometimes 


DISEASES    OF    THE   STOMACH  AND   INTESTINES.  501 

neutral,  and,  under  certain  conditions  which  no  longer  may  be  looked 
upon  as  absolutely  normal,  slightly  acid.  The  stools  of  these  infants 
have  an  odor  more  or  less  recalling  that  of  stale  cheese ;  in  other  words, 
an  odor  of  decomposition. 

The  Daily  Number  of  Movements. — The  normal  infant,  whether  on 
the  breast  or  the  bottle,  will  have  one,  two,  or  even  three  movements 
daily  when  in  perfect  health.  In  the  breast-fed  infants  these  move- 
ments may  be  small  or  large  and  even  contain  quite  an  amount  of 
fluid  and  still  be  within  the  limits  of  health.  In  the  bottle-fed  in- 
fants, however,  the  stools  are,  as  a  rule,  larger  in  bulk  than  those  of 
the  breast-fed  infants,  and  contain  less  water.  I  have  seen  bottle-fed 
infants  in  perfect  health  who  have  had  as  many  as  four  movements 
daily,  all  having  normal  characteristics.  Infants  may  have  six 
movements  daily  and  still  be  in  perfect  health.  If  the  consistence 
and  color  are  within  normal  limits,  the  number  simply  indicates  the 
amount  of  intestinal  residue,  and  not  disease. 

Bacterial  Flora — -Within  two  or  three  days  after  birth  the  meco- 
nium changes  its  characteristics  and  assumes  those  of  milk  faeces. 
In  the  milk  fseces  of  the  infant  nursed  at  the  breast  we  find  as 
predominant,  first,  a  bacillus  described  by  Tissier,  which  stains 
with  Gram's  stain,  and  which  in  the  crude  specimen  seems  to  occupy 
most  of  the  microscopic  field.  This  is  called  the  Bacillus  bifidus 
communis.  It  is  an  anaerobe.  In  addition  to  this  bacillus,  we  find 
next  in  numbers  the  so-called  Bacillus  acidophilus  of  Moro  and  Fink- 
elstein.  The  latter  also  stains  with  the  Gram  stain.  In  addition  to 
these  two  bacilli,  which  are  found  in  greatest  numbers  in  the  fseces 
of  the  breast-fed  infant,  we  have  a  few  coli  bacilli,  and  also  some 
numbers  of  the  Bacillus  lactis  aerogenes. 

The  faeces  of  the  infant  fed  on  cows'  milk  present  a  much  more 
luxuriant  flora  of  bacteria  than  those  of  the  breast-fed  infant.  There 
are:  (1)  the  Bacillus  coli  communis,  (2)  the  Bacillus  acidophilus  in 
small  numbers,  (3)  other  Gram-staining  bacilli,  (4)  the  Micrococcus 
ovalis  (Escherich  and  Tissier),  (5)  the  enterococcus  of  Thiercelin, 
(6)  a  diplococcus  staining  with  Gram,  (7)  streptococci  and  staphylo- 
cocci, (8)  Sarcina  minuta,  (9)  the  Bacillus  lactis  aerogenes.  The 
Bacillus  lactis  aerogenes  splits  milk  sugar  into  lactic  acid,  carbonic 
acid,  and  water,  and  causes  the  intestinal  contents  to  become  acid. 
In  the  lower  part  of  the  gut  we  find  the  Bacillus  coli  communis,  a 
micro-organism  which  may  exist  in  the  presence  of  any  reaction,  and 
which  splits  milk  sugar  into  lactic  acid,  carbonic  acid,  and  water,  and 
partly  splits  fat  into  fatty  acids.  It  is  the  prevalent  micro-organism 
in  the  stools,  though  with  it  we  have  a  number  of  the  Bacillus  lactis 
aerogenes,  a  yellow  fluorescent  or  fluidifying  coccus,  three  fluidifying 
cocci,  a  Micrococcus  ovalis,  a  porcelain  coccus,  the  tetrad  coccus,  the 


502  DISEASES   OF    TEE   STOMACH  AXD   IXTESTINES. 

white  and  red  hay  bacillii?.  a  capsule  bacillus,  the  Mouilia  Candida, 
all  of  which  exist  in  varving  numl^ers. 

Acute  Gastric  Dyspepsia  (Indigestion). — Acute  gastric  dvsjoep- 
sia  may  clinically  be  divided  into  two  forms,  that  affecting  infants, 
either  at  the  breast  or  bottle,  and  that  affecting  older  children.  The 
period  of  infancy  is  one  of  frequent  disttirbances.  Mental  excite- 
ment on  the  part  of  the  nurse  may  cause  the  milk  to  disagree  with  a 
breast-fed  infant.  The  ingestion  of  an  undue  quantity  of  breast- 
milk,  even  if  of  good  quality,  may  cause  indigestion.  Certain  articles 
of  food,  if  partaken  of  by  the  mother,  may  cause  gastric  irritation. 
ISTursing  a  breast  in  which  the  milk  has  caked  will  also  cause  indi- 
gestion. 

Ssrmptoms. — Vomiting  is  the  first  evidence  of  disturbance  of  the 
digestive  processes  in  the  infant.  It  occurs  after  feeding,  and  is  at 
first  not  accomj^anied  by  constitutional  symptoms  or  diarrhoea.  If 
the  exciting  cause  continues,  a  slight  febrile  movement  is  noted,  and 
also  slight  prostration.  The  infant  is  restless,  but  having  vomited  is 
relieved,  and  if  permitted  will  again  take  the  breast,  or  bottle,  the 
vomiting  taking  place  after  each  nursing.  The  bowel  movements 
then  become  disturbed.  They  may  not  only  be  green,  but  also  frequent 
and  in  some  cases  fluid.     There  are  in  all  cases  colic  and  tympanites. 

Acute  gastric  dyspepsia  in  older  children  may  be  caused  by  some 
article  of  diet  which  has  disagreed  with  the  patient.  The  symptoms 
are  much  the  same  as  those  seen  later  in  life.  It  is  important  both 
with  infants  and  children  to  determine  whether  the  symptoms  are 
due  to  improper  food  or  whether  proper  food  has  for  some  reason  dis- 
agreed. Bottle-fed  infants  are  liable  to  indigestion  if  the  milk  con- 
tains any  extraneous  substances,  not  necessarily  toxic  ones. 

A  baby  may  have  thrived  for  weeks  on  a  certain  food-mixture, 
when  suddenly,  without  apparent  cause,  symptoms  of  gastric  dyspep- 
sia supervene.  In  such  cases  it  will  be  found  that  the  acidity  of  the 
milk  was  greater  than  usual,  or  that  the  fodder  of  the  cows  furnishing 
the  milk  has  been  changed.  In  some  cases  the  infant,  whether  on 
the  breast  or  bottle,  will  spit  up  curds  of  an  exceedingly  acid  nature 
or  vomit  a  watery  acid  substance  after  feeding. 

Course. — If  the  food  is  suspended  and  jDroper  treatment  instituted, 
the  symptoms  subside  and  the  infant  recovers,  but  if  the  exciting 
cause  is  not  removed,  more  serious  disturbance  of  the  stomach  and 
gut  will  develop. 

Treatment. — It  is  best  both  with  breast-fed  and  bottle-fed  infants 
to  discontinue  the  giving  of  all  food  as  soon  as  symptoms  of  indiges- 
tion appear.  With  the  suspension  of  food  the  administration  of  a 
simple  cathartic  (castor  oil)  is  all  that  is  necessary.  The  infant  is 
l>ut  for  twelve  hours  on  a  solution  of  white  of  egg,  and  the  breast 


DISEASES   OF   THE   STOMACH  AND   INTESTINES.  503 

pumped  regularly  every  three  hours  to  prevent  caking.  The  breast 
may  then  be  cautiously  exhibited.  Stomach  v^^ashing  should  not  be 
resorted  to,  and  the  breast  should  not  be  denied  for  too  long  a  period. 
If,  on  resuming  breast-feeding,  symptoms  reappear,  an  analysis  of 
the  milk  should  be  made.  Its  composition  may  have  changed  and 
too  much  fat  may  be  present.  We  should  not  be  hasty  in  taking  an 
infant  from  the  breast  and  placing  it  on  the  bottle  on  account  of  a 
few  symptoms  of  gastric  dyspepsia.  Proper  regulation  of  the  diet 
and  the  taking  of  proper  exercise  by 'the  nurse  will  frequently  cause 
the  desired  adjustment  of  the  constituents  of  the  milk  and  the  disap- 
pearance of  symptoms. 

Habitual  Vomiting  of  Infants. — Habitual  vomiting  of  infants 
refers  to  the  regurgitation  of  milk  in  the  uncoagulated  state  shortly 
after  nursing.  It  occurs  in  infants  in  apparently  good  health,  and 
is  not  followed  by  loss  of  weight  or  disturbance  in  the  functions  of  the 
'gut.  Some  infants  vomit  curdled  milk  in  the  same  manner.  The 
cause  of  this  form  of  vomiting  has  been  variously  explained.  The 
simplest  explanation  is,  that  by  slight  pressure  the  food  is  forced  into 
the  oesophagus  and  thence  reaches  the  mouth.  It  is  a  well-known  fact 
that  the  stomach  of  the  infant  can  be  emptied  by  gentle  abdominal 
l^ressure.  Another  explanation  is  that  on  deep  inspiration  the  nega- 
tive pressure  caused  by  descent  of  the  diaphragm  forces  a  certain 
amount  of  fluid  from  the  stomach,  which  is  almost  vertical  in  the 
infant,  into  the  oesophagus  and  thence  into  the  mouth.  This  form  of 
vomiting  requires  no  treatment.  The  general  impression  is  that  it 
can  be  stopped  by  regulating  the  amount  of  breast-feeding,  but  this 
belief  is  erroneous,  as  the  vomiting  persists  after  such  precautions 
have  been  adopted.  Fleischman  thinks  that  the  habit  is  hereditary 
in  certain  families. 

Cyclic  Vomiting  (Periodic  vomiting;  Recurrent  vomiting). — 
Definition.' — Cyclic  vomiting  is  a  condition  in  which  there  appear  at 
intervals  more  or  less  remote  from  each  other  attacks  of  vomiting, 
accompanied  by  marked  prostration  without  rise  of  temperature,  in 
which  there  is  an  absolute  intolerance  of  the  stomach  for  even  fluid 
food.  This  condition  has  been  described  under  various  headings 
both  in  France,  1841,  by  Dr.  Gruere;  by  Lombare,  in  1861;  in 
England  by  Gee,  and  in  America  by  Eotch,  Holt,  Rachford,  Edsall, 
Koplik,  and  others. 

Etiology. — The  etiology  of  this  condition  is  obscure,  and  it  is  most 
probable  that  the  theory  of  Rachford  is  correct — that  the  symptom- 
complex  is  one  of  gastro-intestinal  lithsemia,  due  to  an  increased 
acidity  of  the  fluids  of  the  body  as  the  result  of  disturbed  metabolism. 
In  one  of  these  cases  Herter  has  analyzed  the  amount  of  uric  acid  in 
the  periods  preceding,  during,  and  following  the  attack.     In  such  an 


504  DISEASES    OF   THE   STOMACH  AND   INTESTINES. 

analysis  the  gross  amount  of  uric  acid  was  greatest  on  the  second  day 
of  the  disease,  and  fell  rapidly  on  the  third  day  to  near  the  normal. 
The  normal  relation  of  nric  acid  to  urea  in  these  patients  was  as  1 :  54. 
During  the  attack  the  relation  of  uric  acid  to  urea,  as  a  rule,  was 
1 :  85,  and  in  the  normal  condition  it  fell  to  1 :  42.  Griffith  considers 
the  condition  a  species  of  toxaemia. 

It  seems  to  me,  from  a  study  of  a  number  of  my  own  cases,  that 
the  condition  described  by  Rachford  must  obtain;  in  addition,  how- 
ever, these  are  crises  in  which  the  patients  seem  to  suffer  distinctly 
from  attacks  of  intestinal  intoxication,  inasmuch  as  treatment  directed 
toward  placing  the  conditions  in  the  gut  on  a  normal  basis  seems  to 
benefit  them  materially.  In  most  of  my  own  cases  there  has  been  a 
history  of  constipation  extending  over  long  periods  of  time,  and  an 
intolerance  of  milk  as  the  main  article  of  diet  in  other  cases. 

Other  observers  (Holt)  have  not  found  constipation  to  be  a  promi- 
nent factor  in  their  cases,  but  rather  that  the  ingestion  of  certain 
forms  of  foods,  such  as  amylacea,  are  apt  to  precipitate  an  attack.  In 
only  one  of  my  cases  have  I  found  that  amylacea  were  badly  borne, 
and  the  ingestion  in  this  case  of  a  cereal  gruel  seemed  to  precipitate 
an  attack ;  constipation,  however,  existed  in  this  case  from  infancy. 

Symptoms. — The  symptoms  in  these  cases  are  quite  characteristic ; 
the  subjects  of  this  form  of  disturbance  may  be  well  developed,  but, 
as  a  rule,  they  are  pale.  In  some  of  them  the  anaemia  is  quite 
marked,  and  the  children  have  a  pasty  complexion.  The  attack  is 
preceded  by  a  period  during  which  the  child  complains  of  slight  pain 
in  the  stomach ;  in  some  cases  this  may  be  absent.  The  child  awakens 
in  the  morning,  feels  tired,  has  no  appetite  for  breakfast,  and  has 
pronounced  pallor.  Vomiting  sets  in;  the  food  is  first  rejected  and 
then  vomiting  persists ;  in  some  cases  even  blood  with  mucus  is  vom- 
ited from  the  stomach.  In  other  cases  the  contents  of  the  duodenum 
may  appear  in  the  vomitus  in  the  form  of  biliary  matter.  The  child 
finds  most  comfort  in  lying  quietly  on  its  back,  refusing  to  take  any 
food ;  even  water  is  vomited.  There  is  no  temperature ;  there  may 
be  a  slight  increase  of  the  pulse-rate,  and  it  may  have  a  bounding 
character,  and  the  heart-impulse  may  be  increased  in  force.  There 
may  be  a  complaint  of  epigastric  pain.  The  prostration  in  some  cases 
is  extreme ;  the  condition  may  last  twenty-four  hours  to  two  or  three 
days,  until  normal  conditions  are  established.  The  vomiting  may 
recur  several  times  in  twenty-four  hours;  it  gradually  diminishes  in 
frequency  and  disappears.  During  this  time  there  is  no  movement 
from  the  bowels,  or  there  may  be  a  constipated  movement  as  the  result 
of  enemata,  with  the  voidance  of  a  large  quantity  of  mucus.  The 
stools  have  an  exceedingly  offensive  odor.  The  following  is  a  char- 
acteristic case: 


DISEASES    OF    THE   STOMACH  AND   INTESTINES.  505 

Dorothy  E.,  five  years  of  age,  fed  in  infancy  on  modified  milk; 
has  never  suft'ered  from  any  disease  of  greater  severity  than  a  grippal 
attack.  She  has  been  constipated  since  infancy,  and  this  constipa- 
tion has  lately  become  more  marked.  After  having  been  put  on  raw 
milk  and  cream,  the  constipation  abated  for  a  few  weeks  and  then 
returned.  The  constipation  was  only  relieved  by  the  constant  use 
of  cathartics,  and  sometimes  these  were  not  effective.  The  child  is  a 
well-developed  girl,  thirty-five  pounds  in  weight,  with  a  body-length 
of  102  cm.  (3  feet  4  inches)  ;  the  abdomen  is  protuberant;  there  is 
no  disease  of  the  heart  or  lungs ;  the  liver  and  spleen  are  normal  in 
size.  The  urine  does  not  contain  albumin  or  casts.  The  child  is 
anaemic,  has  a  tired  expression,  and  her  intestinal  movements  contain 
considerable  mucus.  Her  vomiting  attacks  began  when  she  was  four 
years  of  age.  These  attacks  last  two  or  three  days,  during  which  the 
child  rejects  all  food.  The  attacks  begin  very  much  in  the  manner 
just  described.  In  one  of  these  attacks  the  vomiting  was  so  severe 
that  there  was  an  alarming  hemorrhage  from  the  stomach.  The  odor 
of  the  breath  in  the  first  day  of  the  attack  is  "sweetish"  (acetone). 

Some  of  my  cases  during  the  attacks  presented  albumin  and  a 
few  hyaline  casts  in  the  urine.  These  disappeared  after  subsidence 
of  the  attack.  Acetone  bodies  may  be  present  in  the  urine  in  in- 
creased quantity,  or  they  may  be  absent. 

Diagnosis. — The  practitioner  should  be  exceedingly  cautious  when 
presented  with  a  case  of  vomiting  in  a  child  from  four  to  five  years 
of  age  not  to  hastily  conclude  that  it  is  one  of  cyclic  vomiting  before 
making  a  thorough  examination,  not  only  of  the  urine,  but  of  the 
other  viscera. 

A  case  has  recently  come  under  my  notice,  observed  for  four  years, 
in  which  a  diagnosis  was  made  of  cyclic  vomiting,  but  which  is  one 
distinctly  of  nephritis  with  recurrent  attacks  of  ursemia.  Other 
cases  may  be  masked  appendical  attacks. 

Some  authors,  such  as  Rotch,  have  laid  stress  on  the  fact  that  these 
attacks  may  also  simulate  meningitis. 

Course  and  Prognosis. — The  prognosis  in  this  condition,  so  far  as 
life  is  concerned,  is  good.  There  are  some  cases  recorded  which  have 
terminated  fatally.  The  course  of  the  disease,  if  properly  handled, 
ends,  as  a  rule,  in  recovery  in  from  twenty-four  hours  to  three  or 
four  days. 

Treatment. — The  treatment  of  cyclic  vomiting  is  divided  into  the 
treatment  of  the  attack  and  the  intervals  between  the  attacks. 

The  Attach. — The  patient  is  put  to  bed,  kept  perfectly  quiet,  and 
little  or  no  fiuid  is  given  by  the  stomach- — certainly  no  solid  food. 
The  stomach  is  quieted  with  small  doses  of  codeia.  This  is  the  only 
remedy  which  in  my  hands  seems  to  have  had  any  influence  in  con- 


506  DISEASES   OF    THE   STOMACH  AND   INTESTINES. 

trolling  prolonged  vomiting.  Enemata  consisting  of  saline  solution 
are  given  twice  daily.  They  should  be  high  enemata,  and  at  least  a 
quart  of  water  should  be  thrown  into  the  rectum  at  each  sitting.  In 
the  intervals  between  the  enemata  the  child  should  be  nourished  by 
the  rectum.  Somatose  solution^ — 1  drachm  of  somatose  to  8  ounces 
of  cold  water — is  heated  to  a  lukewarm  temperature,  and  given  by 
the  rectum  in  quantities  varying  from  2  to  4  ounces  every  three 
hours.  The  patient  is  given  small  pieces  of  ice  to  swallow,  in  the 
case  of  older  children.  'No  other  treatment  is  necessary  until  the 
attacks  of  vomiting  subside  of  their  own  accord  within  twenty-four 
hours.  It  is  surprising  to  see  how  comfortable  these  little  patients 
will  be  if  little  or  no  fluid  is  taken  by  the  mouth;  in  fact,  some  of 
them  are  intelligent  enough  to  find  this  out  for  themselves  and  refuse 
all  nourishment.  On  the  second  day  of  the  disease,  when  the  vomit- 
ing has  subsided  to  a  great  extent,  we  may  give  the  patient  broths, 
fruit  juices,  diluted  gruels;  and  on  the  third  day  we  may  gradually 
return,  if  the  stomach  is  tolerant,  to  a  semi-solid  diet,  and  finally  to 
a  full  diet.  As  soon  as  the  stomach  is  tolerant  of  fluids,  and  even  at 
the  height  of  the  attack,  small  quantities  of  Vichy  given  by  the 
stomach  seem  to  be  grateful  to  the  patient.  During  this  period  also 
the  alkaline  treatment,  which  will  be  spoken  of,  may  be  inaugurated ; 
and  finally  we  may,  toward  the  close  of  the  attack,  if  this  is  possible, 
give  a  vigorous  cathartic,  such  as  cascara,  or  Rochelle  salts. 

The  Intervals. — In  the  intervals  between  the  attacks  these  patients 
do  best  on  the  following  treatment :  The  bowels  should  be  kept  in  a 
normal  condition;  if  the  child  is  constipated  a  rectal  enema  should 
be  given  daily,  and,  if  this  is  not  effective,  it  should  be  supplemented 
by  some  cathartic,  such  as  cascara,  in  order  to  facilitate  a  complete 
daily  evacuation  of  the  bowel.  The  diet  in  these  children  should  be 
a  mixed  one.  I  have  found  that  whereas  some  of  these  children  will 
not  tolerate  cereals,  others  will.  The  rule,  however,  is  that  we  should 
reduce  the  quantity  of  milk,  especially  in  the  older  children,  to  a 
minimum,  and,  if  possible,  place  the  patient  on  a  diet  in  which  milk 
enters  but  little.  They  should  be  placed,  so  far  as  medicinal  agents 
are  concerned,  on  the  so-called  alkaline  treatment,  which  has  been 
found  to  be  most  successful  in  these  cases.  For  a  child  from  three 
to  five  years  of  age  I  prescribe  a  powder  composed  of  2  to  3  grains 
of  bicarbonate  of  soda  and  -|-  to  -J  grain  of  carbonate  of  lithium.  This 
powder  is  given  three  times  daily  after  meals  in  a  glass  of  Vichy 
Celestins.  The  children  are  bathed  daily  in  a  bath  in  which  a  hand- 
ful of  bicarbonate  of  soda  and  a  handful  of  salt  have  been  dissolved. 
and  are  rubbed  down  after  the  bath  with  a  very  dilute  solution  of 
alcohol  in  water  and  a  rough  towel.  The  muscles  of  the  body  are 
kneaded,  if  a  masseuse  is  available.     Sojourn  in  the  open  air  as 


DISEASES   OF    THE   STOMACH  AND   INTESTINES.  507 

mucli  as  possible  is  advised,  and  sports  which,  involve  muscular  exer- 
tion encouraged.  Regularity  at  meals  is  inculcated,  and  these  little 
dues  are  taught,  if  possible,  to  evacuate  the  bowel  regularly.  In 
some  of  these  cases  the  coarser  the  diet,  the  more  successful  seems  to 
be  the  treatment,  for  in  the  most  aggravated  cases  that  I  have  seen 
there  has  been  a  too  "  finicky  "  selection  of  a  few  articles  of  diet  for 
these  patients,  and  the  little  ones  have  been  kept  in  some  cases  on 
milk,  gruels,  and  fruits,  to  the  exclusion  of  everything  else,  for 
months. 

'     Other  Forms  of  Vomiting. — There  are  other  forms  of  vomiting 
which  are  of  interest  in  this  connection: 

a.  Some  children  vomit  when  irritated  or  after  outbursts  of  tem- 
per, or  may  vomit  at  will  if  their  food  or  anything  in  connection  with 
their  discipline  does  not  meet  their  approval.  Some  of  the  little 
patients  know  intuitively  that  vomiting  alarms  the  mother,  conse- 
tf'tiently  it  will  appear  whenever  any  concession  is  to  be  obtained  in 
the  nursery. 

h.  Vomiting,  especially  after  eating,  may  be  caused  by  a  severe 
attack  of  coughing.  If  vomiting  occurs  frequently  under  these  con- 
ditions, whooping-cough  should  be  suspected. 

c.  The  vomiting  of  pyloric  stenosis  of  the  congenital  type  is  char- 
acteristic. It  is  more  in  the  nature  of  a  regurgitation.  When  lying 
oh  the  back  the  baby  vomits  at  intervals,  and  in  small  quantities. 
After  a  nursing  there  is  an  interval,  after  which  the  infant  vomits 
two  or  three  times  the  amount  of  food  taken  at  the  recent  nursing. 
This  is  explained  by  the  fact  that  in  this  condition  there  is  some  little 
vomiting  constantly  going  on,  due  to  the  increased  peristalsis  of  the 
stomach.  There  is,  however,  a  small  quantity  of  food  retained  in  the 
stomach.  This  residual  quantity  increases  with  each  feeding,  and  is 
finally  rejected  in  the  manner  just  described. 

d.  The  vomiting  of  appendicitis  is  also  characteristic.  The  pa- 
tient is  seized  suddenly  with  sharp  abdominal  pain  and  then  begins  to 
vomit.  The  vomiting  may  recur  once  or  twice,  and  then  cease.  In 
neglected  cases,  in  the  final  agonal  stage,  vomiting  due  to  sepsis  and 
toxaemia  may  be  persistent. 

e.  Vomiting  is  the  first  symptom  in  intestinal  obstruction.  It 
may  be  followed  by  a  very  small  movement,  and  then  for  a  short 
time  there  is,  as  a  rule,  no  action  on  the  part  of  the  bowels.  The 
vomiting  may  not  recur  in  the  first  twenty-four  or  forty-eight  hours, 
except  at  long  intervals,  but  the  bloody  movements  recur  frequently, 
and  pain  is  also  present.  The  vomiting  returns  when  the  intussus- 
ception is  more  marked,  and  late  in  the  affection  becomes  fsecal. 

/.  Vomiting  occurs  at  the  outset  of  the  infectious  diseases.     Per- 


508  DISEASES   OF    THE   STOMACH  AND   INTESTINES. 

sistent  vomiting  extending  over  a  period  of  months  is  often  of 
nephritic  origin. 

g.  The  vomiting  which  accompanies  meningitis  occurs  at  the  out- 
set in  that  disease,  and  is  quickly  followed  by  cerebral  symptoms. 
In  tuberculous  meningitis  it  occurs  at  the  onset  and  after  the  appear- 
ance of  a  vague  series  of  cerebral  symptoms.  It  is  rarely  persistent 
after  the  initial  attack.  The  subsidence  of  the  vomiting  and  the 
sequence  of  cerebral  symptoms  and  a  febrile  movement  will  easily 
distinguish  this  form  of  vomiting  from  others. 

Tumors  and  abscess  of  the  brain  are  accompanied  by  vomiting  at 
intervals.  There  is  in  these  and  in  all  cerebral  cases  persistent,  severe 
localized  headache. 

Colic. — Colic  is  not  a  disease,  but  a  symptom  of  disturbed  con- 
ditions in  the  intestine.  It  is  really  a  painful  contraction  of  the 
muscle-fibre  of  portions  of  the  intestine.  In  the  simplest  form  the 
painful  contractions  are  incited  by  actual  distention  of  the  lumen  of 
the  intestine.  The  pain  caused  in  colic  is  in  the  majority  of  cases 
not  of  the  character  which  arises  in  certain  other  affections  of  the 
intestine  which  are  neurotic  in  nature,  nor  is  it  of  the  same  nature 
as  that  seen  in  enteritis.  Pain  similar  to  that  in  colic  may  be  caused 
by  the  administration  of  some  such  drug  as  lead,  arsenic,  etc. 

Cause. — In  the  great  majority  of  cases  the  affection  is  caused  by 
some  disturbance  of  the  processes  of  assimilation.  It  is  uncommon 
in  infants  in  good  condition,  and  its  appearance  in  any  case  indi- 
cates the  necessity  of  a  study  into  the  condition  of  the  digestive 
processes  in  the  stomach  and  intestine.  The  form  of  pain  or  colic 
accompanied  by  distention  (tympanites)  seen  in  newborn  infants, 
and  also  at  the  height  of  pneumonia  in  older  children,  has  an  etiology 
distinct  from  that  of  the  ordinary  variety.  ISTot  only  is  the  pain 
of  neurotic  origin,  but  also  the  distention  is  a  result  of  paralysis  of 
the  muscular  fibre  of  the  intestine.  The  intestinal  processes  may  be 
disturbed  as  a  result  of  the  pneumonia.  Colic  may  occur  in  breast- 
fed or  in  artificially  fed  infants.  In  the  former  it  is  not  always  pos- 
sible to  discover  the  exact  cause.  The  breast  milk  may  be  abundant, 
of  good  color,  and  of  correct  composition,  and  still  there  may  be  very 
violent  colicky  pains.  In  artificially  fed  infants  the  cause  of  the 
colic  may  lie  in  the  very  nature  of  the  food  (cows'  milk)  and  the  diffi- 
culty of  complete  assimilation.  Thus  an  excess  of  fats  in  the  milk 
cause  colic. 

Symptoms. — An  attack  of  colic  is  preceded  by  general  uneasiness; 
the  infant  cries  and  cannot  be  quieted.  The  severe  colicky  pain  is 
accompanied  by  sharp  crie-,  the  arms  and  lower  extremities  are  drawn 
up,  and  the  abdomen  is  rigid.  After  the  passing  of  gas  the  infant 
is  quieted  and  falls  asleep  quite  exhausted.     These  attacks  of  colic 


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DISEASES    OF    TEE   STOMACH   AND   INTESTINES.  509 

dej^rive  the  infant  of  sleep ;  they  may  or  may  not  be  accompanied  by 
tympanites.  The  movements  are  rarely  normal,  or  may  be  normal 
for  some  days  and  then  take  on  a  curdy  character  or  become  greenish. 
Sometimes  the  colicky  attacks  are  accompanied  by  a  mild  form  of 
diarrhoea ;  the  pain  may  be  so  severe  as  to  cause  convulsions. 

Treatment. — See  below  under  Tympanites. 

Tympanites. — Tympanites  is  a  condition  of  distention  of  the  in- 
testine with  gas,  which  may  supervene  in  inflammatory  states  of  the 
peritoneum.  In  such  conditions  (peritonitis,  appendicitis)  the  paral- 
ysis of  the  muscular  wall  of  the  intestine  is  the  real  cause  of  the  dis- 
tention. In  other  states,  such  as  pneumonia,  it  may  be  the  result  of 
inefficient  action  of  the  diaphragm  in  not  expelling  the  intestinal 
gases  and  of  an  enteric  catarrh  which  sometimes  accompanies  that 
disease.  In  the  newborn  infant,  tympanites  is  a  result  of  an  inherent 
muscular  weakness  of  the  intestinal  wall.  In  colic  due  to  imperfect 
assimilative  processes,  the  tympanites  is  due  to  the  formation  of  gases 
of  which  the  intestine  is  unable  to  rid  itself  rapidly  (Plate  XXVIII. ). 

In  pneumonia  the  tympanitic  distention  is  sometimes  extreme, 
causes  great  distress,  and  is  frequently  mistaken  for  peritonitis.  In 
the  forms  of  distention  in  the  newborn  infant  the  distress  is  not  so 
great.  In  rachitis  there  is  a  state  of  tympanitic  distention  of  the 
abdomen  due  not  only  to  defective  assimilative  processes,  but  also  to 
a  lax  condition  of  the  muscle-fibre  of  the  intestinal  walls. 

Treatment  of  Colic  and  Tympanites. — If  the  food  of  a  bottle-fed 
infant  is  at  fault,  the  modification  of  milk  must  be  altered  so  that  the 
proportion  of  the  fats  may  be  lower.  A  reduction  of  fat  will  not 
always  remedy  the  condition;  the  proportion  of  sugar  is  sometimes 
at  fault,  especially  in  infants  fed  on  condensed  milk.  Xot  more  than 
6  per  cent,  of  sugar  should  be  added  to  any  milk  modification.  Some 
infants  can  take  a  large  quantity  of  malt-sugar  in  their  food  and  not 
suffer  from  colic.  If  a  breast-fed  infant  suffers  from  colic,  the 
hygiene  of  the  nurse  should  be  attended  to.  If  after  the  taking  of 
exercise  and  regulation  of  diet  the  colic  persists  and  becomes  a  fea- 
ture in  the  case,  the  wet-nurse  should  be  changed. 

The  attack  of  colic  is  best  combated  by  giving  the  infant  an 
enema.  In  some  cases  a  small  amount  of  dilute  hydrochloric  acid 
and  pepsin  given  three  times  daily  will  alleviate  the  symptoms.  In 
other  cases  a  small  dose  of  pancreatic  extract  and  bicarbonate  of 
soda  will,  after  feeding,  succeed  in  alleviating  symptoms.  If  in 
spite  of  all  efforts  an  artificially  fed  baby  suffers  with  colic  and  does 
not  increase  regularly  in  weight,  it  should  be  placed  at  the  breast. 

Dilatation  of  the  Stomach. — Etiology. — Dilatation  of  the  stomach 
may  be  due  to  mechanical  causes,  such  as  stenosis  of  the  pylorus, 
resulting  in  overfilling  of  the  stomach,  with  consequent  dilatation ;  or 


510  DISEASES    OF    THE   STOMACH   AND   INTESTINES. 

it  may  be  caused  bj  muscular  atony,  such  as  is  present  in  general 
atrophy  or  rachitis.  In  mechanical  stenosis  of  the  pylorus  the  mus- 
cular structures  are  intact  at  first ;  hypertrophy  subsequently  appears 
in  the  region  of  the  pylorus,  with  secondary  dilatation  of  the  fundus 
of  the  stomach.  An  hour-glass  distortion  of  the  form  of  the  stomach 
and,  subsequent  to  this,  a  sausage-shaped  dilatation  of  the  organ 
result,  the  long  diameter  of  the  dilatation  being  in  the  long  axis  of 
the  stomach.     This  last-named  deformity  is  permanent. 

The  location  of  a  dilated  stomach  in  the  child  differs  somewhat 
from  that  in  the  adult.  The  pylorus  in  the  child  lies  deepest  and 
near  the  umbilicus  in  the  mid-line;  the  fundus  lies  transversely  across 
the  abdomen  at  the  situation  of  the  umbilicus ;  whereas  in  the  vicinity 
of  the  border  of  the  ribs  it  passes  abruptly  upward.  The  muscular 
coat  of  the  stomach  in  these  cases  is  thin  and  atrophic.  If  there  is 
overloading  of  the  stomach,  or  the  ingestion  of  indigestible  sub- 
stances, the  organ  is  not  thoroughly  emptied,  and  as  a  result  there  are 
fermentation  and  accumulation  of  food  in  the  stomach.  Muscular 
relaxation  results,  and  then  atrophy  of  an  otherwise  weak  muscula- 
ture. In  arthrepsia  and  rachitis  the  musculature  of  the  stomach  is 
primarily  weak,  and  repeated  attacks  of  dyspepsia  with  overloading 
result  in  dilatation. 

Symptoms. — The  symptoms  of  dilatation  of  the  stomach  as  a  result 
of  pyloric  stenosis  are  described  elsewhere.  As  a  result  of  chronic 
dyspepsia  and  overloading  of  the  stomach  in  younger  children  there 
are  at  first  the  ordinary  symptoms  of  evanescent  dyspepsia.  There  is 
vomiting  after  meals,  and  after  a  time  this  vomiting  takes  place  after 
the  food  has  accumulated  in  the  stomach.  With  the  attacks  of  vom- 
iting there  is  loss  of  appetite,  and  finally  an  intolerance  of  all  food, 
even  in  very  small  quantities.  Constipation  follows  as  a  result  of 
lack  of  appetite  and  the  avoidance  of  food.  Meteorism  is  present  in 
some  of  these  cases  ;  whereas  in  others  intestinal  catarrh  may  alternate 
with  the  constipation. 

In  older  children  dilatation  of  the  stomach  results  from  repeated 
attacks  of  dyspepsia  which  extend  over  months.  The  development 
of  the  disease  is  slow.  There  are  loss  of  appetite,  a  feeling  of  ten-, 
sion  and  overloading  after  meals ;  the  odor  of  the  breath  is  bad ;  the 
tongue  is  coated ;  children  complain  of  headaches ;  the  bowels  are  very 
irregular,  sometimes  constipated ;  and  finally  vomiting  after  meals 
sets  in.  The  vomited  matter  contains  not  only  particles  of  food,  but 
sarcinse  and  other  species  of  bacteria.  The  reaction  of  the  stomach- 
contents  may  be  neutral  or  acid,  the  hydrochloric  acid  and  propeptone 
may  be  increased  or  may  vary  on  different  days ;  lactic,  butyric,  and 
acetic  acids  may  be  present  in  the  vomited  matter  as  a  result  of 
fermentation. 


DISEASES    OF    THE   STOMACH   AND    INTESTINES.  511 

Physical  Signs. — The  physical  signs  consist  of  persistoit  meteor- 
ism  and  tympanites.  The  abdomen  is  very  much  enlarged,  and  in 
some  cases  the  stomach  can  be  distinctly  outlined,  especially  the 
greater  curvature.  If  the  child  is  examined  lying  on  its  back,  with 
its  knees  raised  and  the  pelvis  supported  with  one  hand  while  the 
other  taps  the  abdomen  sharply  over  the  situation  of  the  stomach,  the 
distended  organ  will  yield  a  so-called  succussion  sound,  due  to  accu- 
mulated contents  in  the  organ.  In  many  cases  a  dilated  colon  may 
be  mistaken  for  a  dilated  stomach.  By  means  of  gastrodiaphany  the 
author  has  been  able  to  mark  out  quite  distinctly  the  greater  curva- 
ture of  the  stomach. 

Prognosis. — The  prognosis  will  vary  according  to  the  exciting 
cause.  If  the  dilatation  of  the  stomach  is  caused  by  congenital 
stenosis  of  the  pylorus  the  prognosis  is  doubtful ;  if  caused  by  repeated 
attacks  of  gastric  dyspepsia  the  prognosis  is  more  favorable.  It  is 
not  as  favorable  in  severely  rachitic  children,  in  whom  there  may  be 
at  the  same  time  a  progressive  atrophy  of  the  muscular  tissue  of  the 
stomach. 

Treatment. — The  treatment  of  dilatation  of  the  stomach  in  infants 
and  children  does  not  differ  materially  from  the  treatment  of  the 
same  condition  in  the  adult.  In  infants  the  quantity  of  solid  food 
•and  fluids  given  at  each  meal  is  reduced  to  a  minimum.  The  sys- 
tematic washing  of  the  stomach  at  intervals  is  indicated  in  these  cases, 
as  in  older  children  and  adults.  With  older  children  the  amount  of 
fluids  is  also  limited.  Soups  are  excluded  and  milk  is  peptonized. 
Bread,  meat,  and  digestible  substances  are  preferred  to  fluids.  In 
these  cases  also  the  stomach  is  washed  systematically. 

The  medical  treatment  of  these  cases  consists  in  the  administra- 
tion of  hydrochloric  acid,  pepsin,  general  hygiene,  massage,  faradiza- 
tion of  the  stomach  in  severe  cases,  as  in  the  adult. 

Ulcer  of  the  Stomach. — Ulcer  of  the  stomach  may  occur  as  a 
complication  in  sepsis  of  the  newborn,  in  acute  gastritis,  and  in  tuber- 
culosis. As  a  primary  disease,  this  affection  is  very  rare  in  infancy 
and  childhood,  although  cases  are  reported  in  the  literature  as  a  com- 
plication of  infectious  diseases,  such  as  scarlet  fever,  typhoid  fever, 
measles,  tuberculosis.  Reimer  records  a  case  in  a  child  three  and  a 
half  years  of  age.  Hibbard  met  a  case  in  an  infant  four  months  of 
age.  Botch  reports  a  case  in  an  infant  seven  weeks  old.  It  is  rare, 
however,  between  the  ages  of  one  and  ten  years.  In  226  autopsies 
Brinton  saw  it  twice.  I  have  seen  it  at  an  autopsy  in  a  case  of  em- 
pyema. It  occurs  in  chlorotic  girls  toward  the  age  of  puberty,  and 
is  not  essentially  a  disease  of  infancy  and  childhood. 

Congenital  Pyloric  Spasm  and  Congenital  Hypertrophic  Stenosis 
of  the  Pylorus     {Congenital   Stenosis   of   the  Pylorus;   Congenital 


512  DISEASES   OF    THE   STOMACH  AND   INTESTINES. 

Hypertrophy  of  the  Pylorus  and  Stomach-waU;  Congenital  Gastric 
Spasm).- — Hypertrophic  pyloric  stenosis  is  a  congenital  condition 
which  appears  from  a  few  days  to  several  weeks  (three  months)  after 
birth,  and  manifests  itself  in  persistent  vomiting.  In  a  few  instances 
several  infants  in  the  same  family  have  been  thus  affected. 

The  first  case  of  pyloric  stenosis  was  described  by  Dr.  Beardsley 
in  the  Transactions  of  the  New  Haven  Medical  Society  (Osier). 

Landerer  (1879),  Maier  (1885),  and  Hirschsprung  (1887)  re- 
opened the  study  of  this  affection. 

Etiology. — The  etiology  of  the  affection  is  obscure.  Since  in  the 
majority  of  the  cases  which  have  been  carefully  studied  the  infants 
were  overfed  or  improperly  fed,  it  is  supposed  that  some  irritant  to 
the  stomach  is  the  exciting  cause.  Thomson,  who  has  made  careful 
studies  of  these  cases,  believes  that  the  condition  originates  in  intra- 
uterine life,  and  is  due  to  the  ingestion  of  liquor  amnii.  This  fluid, 
by  irritating  the  mucous  membrane  of  the  stomach,  excites  both  that 
organ  and  the  pylorus  to  overaction.  Pf aundler  denies  that  there  is 
a  true  hypertrophy  of  the  pylorus,  and  asserts  that  the  condition 
during  life  is  that  of  functional  spasm.  The  postmortem  condition 
is  due  to  toxic  agonal  contracture  of  the  pylorus. 

Another  theory  is  that  congenitally  there  may  be  some  narrowing 
of  the  orifice  of  the  pylorus,  but  not  sufficient  to  prevent  the  passage 
of  food.  Such  infants  are  immediately  after  birth  in  apparent 
health  and  only  later  the  spasm  amounting  to  a  real  stenosis  of  the 
pylorus  makes  its  appearance,  due  to  an  increased  acidity  of  the  con- 
tents of  the  stomach  reacting  on  a  sensitive  mucous  membrane  and 
causing  a  spasm  of  the  already  impaired  sphincter.  This  acidity  is 
supposed  to  be  due  to  improper  feeding  or  excess  of  some  element  of 
the  food  such  as  fat. 

Morbid  Anatomy. — The  stomach  and  CEsophagus  have  been  found 
to  be  dilated  in  fully  one-third  of  the  reported  cases.  The  mucous 
membrane  shows  the  usual  change,  such  as  the  congestion  which  is 
seen  in  a  stomach  in  which  there  have  been  functional  disturbances. 
The  mucous  membrane  of  the  pylorus  is  thrown  into  voluminous  folds. 
The  lumen  has  in  some  cases  been  found  patent  to  a  small  probe,  but 
fluids  cannot  be  forced  from  the  stomach  through  the  pylorus  (Thom- 
son). The  muscular  fibres  show  characteristic  change.  The  circular 
fibres  are  thickened  and  hypertrophied  (Thomson).  In Finkelstein's 
case  the  longitudinal  fibres  were  also  thus  affected.  Some  deny  this 
hypertrophy  and  contend  that  it  is  an  agonal  contraction. 

Classes  of  Cases. — To  my  mind  there  are  two  distinct  sets  of  cases 
which  give  rise  to  symptoms  to  be  detailed.  In  one  set  there  is  a  dis- 
tinct spasm  of  the  pylorus  and  stomach  without  any  marked  hyper- 
trophy and  with  a  limited  amount  perhaps  of  stenosis  of  the  pylorus. 


DISEASES   OF   TEE   STOMACH  AND   INTESTINES.  513 

After  a  time  such  cases  improve  and  eventually  recover,  leaving  no 
trace  of  the  illness  in  the  patient. 

In  the  other  set  there  is  a  congenital  condition  of  marked  stenosis 
of  the  lumen  of  the  pylorus  and  to  this  there  is  superadded  a  spasm 
vsrhich  causes  this  lumen  to  become  completely  obstructed.  To  this 
is  added  a  marked  hypertrophy  of  the  muscular  fibres  v^hich  enter 
into  the  structure  of  the  pylorus.  The  mucous  membrane  and  mus- 
cular coats  are  thickened  and  thrown  into  obstructing  folds  of  tissue. 
In  a  great  many  instances  this  condition  admits  of  improvement. 
The  spasm  relaxes,  the  lumen  of  the  pylorus  opens  up  and,  though  it 
may  remain  narrovt^ed,  under  correct  diet  the  patient  improves  and 
increases  in  weight.  I  have  published  such  cases  as  well  as  cases 
illustrating  the  purely  spastic  condition  of  the  pyloric  orifice. 

Symptoms. — Infants  in  whom  this  condition  is  present  are  of 
normal  weight  and  appearance  when  born.  The  great  majority  of 
them  have  been  breast-fed ;  I  should  say  from  the  literature  that  fully 
two-thirds  of  the  children  were  breast-fed  from  the  start.  After  a 
while,  varying  from  one  to  four  days,  in  other  cases  seven  days,  and 
in  a  great  many  cases  the  third  week  after  birth,  in  exceptional  cases 
the  eighth  week  after  birth,  the  vomiting  begins.  In  a  few  cases,  as 
in  some  of  my  own,  there  is  a  history  that  an  attempt  was  made  to 
feed  the  baby,  in  addition  to  the  breast,  on  the  bottle,  and  in  these 
cases  the  vomiting  began  from  the  attempts  at  mixed  feeding.  In 
other  cases  there  is  no  such  history,  the  mother's  milk  being  the  only 
food ;  the  milk  seemed  to  be  abundant,  and  there  was  no  change  in  the 
milk  or  in  the  mother  to  account  for  the  disturbance  in  the  child. 

The  vomiting  occurs  at  first  at  intervals  throughout  the  twenty- 
four  hours,  and  soon  becomes  persistent,  the  child  rejecting  sometimes 
a  portion  or  all  of  every  nursing.  Sometimes  the  history  will  show 
that  the  infant  has  rejected  more  than  it  had  taken.  This  is  quite 
characteristic,  and  points  toward  a  retention  in  the  stomach  of  some 
of  the  previous  feedings.  With  the  vomiting  there  is  a  steady  ema- 
ciation or  a  stationary  weight.  If  the  weight  is  stationary,  the 
patient  is  fortunate.  If  the  emaciation  is  progressive,  in  a  few 
weeks  an  infant  which  had  been  perfectly  well  at  birth,  weighing  the 
normal  or  above  the  normal,  is  reduced  to  a  distinctly  marantic  con- 
dition. With  the  vomiting  there  are  other  signs  of  constitutional 
disturbance. 

It  seems  that  every  time  the  breast  is  given  to  the  child,  or  within 
a  few  minutes  after  nursing,  there  are  evidences  in  some  cases  of 
pain ;  the  children  will  cry  and  this  will  be  told  to  the  physician  by 
the  mother.  In  addition  there  is  constipation  in  most  cases,  or  the 
movements  are  small,  minimal  in  quantity,  sometimes  fluid  in  con- 

33 


514  DISEASES   OF   THE   STOMACH   AXD   IXTESIIXES. 

sistency,  or  tliey  may  be  greenish.     As  a  rule,  the  movements  indi- 
cate that  very  little  has  passed  through  the  gut. 

Physical  examination  in  these  cases  reveals  in  the  vast  majority 
of  instances  a  characteristic  condition  of  the  surface  of  the  abdomen. 
On  the  introduction  of  food  there  is  a  peristalsis  visible  to  a  greater 
or  less  extent  on  the  surface  of  the  abdonien.  This  peristalsis  begins 
underneath  the  left  costal  border^  passes  forward  to  Traube's  triangle, 
and  there  seems  to  stop,  being  interrupted  by  a  sort  of  groove,  and  is 
taken  u]3  again  by  a  second  wave  of  peristalsis  which  passes  onward 
beyond  the  ensiform  cartilage^  then  downward,  and  disappears  (Fig. 
108). 

Fig.  108. 


Peristalsis  as  seen  in  congenital  pyloric  stenosis.     Case  of  Ibrahim. 

Some  authors  have  described  a  reverse  peristalsis  just  previous  to 
vomiting,  but  I  could  never  convince  myself  of  the  fact,  possibly 
because  I  have  not  seen  these  particular  cases.  If  there  is  a  reverse 
wave  of  peristalsis,  it  must  be  instantaneoiis.  and  I  have  not  yet 
observed  it.  Ibrahim  also  expresses  his  lack  of  information  on  this 
reverse  wave.  In  some  cases  I  have  seen  the  peristalsis  so  extreme 
that  just  previous  to  vomiting  the  stomach  would  in  a  manner  erect 
itself  on  the  abdomen  and  divide  itself  distinctly  from  what  ajDpears 
to  be  the  pyloric  end  of  the  stomach ;  it  would  contract,  and  then  the 
vomiting  would  take  place. 

The  vomiting  is  projectile  in  its  nature,  as  if  there  was  a  sudden 
violent  contraction  of  the  stomach  and  a  forcing  upward  of  the  con- 
tents. In  some  cases  careful  examination  during  this  period  of  con- 
traction and  peristalsis  reveals  a  small  hard  nodule,  cartilage-like  in 
consistency,  situated  sometimes  beneath  the  liver  or  its  border  and 
running  directly  downward  toward  the  umbilicus.  This  structure, 
situated  deeply  against  the  vertebral  column,  is  undoubtedly  the 
pyloric  end  or  valve  of  the  stomach  as  it  meets  the  duodenum. 


DISEASES    OF    THE   STOMACH  AND   INTESTINES.  515 

Some  authors  like  Ibrahim  have  described  singultus  in  these 
cases,  and  also  eructations  of  gas,  but  inasmuch  as  these  are  quite 
common  in  healthy  breast-fed  infants,  it  seems  to  obscure  the  picture 
by  laying  any  stress  upon  them. 

The  peristalsis  which  I  have  described  is  present  in  a  majority 
of  cases,  but  it  is  not  necessarily  an  accompaniment  of  all  of  them. 
It  is  sometimes  entirely  absent  during  the  height  of  the  affection,  and 
is  only  seen  at  times.  The  pylorus  also  may  not  be  palpable,  and  may 
not  be  felt  at  times.  As  to  the  peristalsis,  we  must  be  very  careful 
also  how  we  conclude  as  to  its  presence  or  absence.  A  normal  mild 
form  of  peristalsis  seen  in  emaciated  infants  must  not  be  confounded 
with  the  violent  peristalsis  present  in  some  forms  of  this  affection. 
Some  of  the  most  violent  cases  of  vomiting  with  spasm  or  congenital 
stenosis  of  the  pylorus  have  passed  through  my  hands  without  the 
detection  of  the  situation  of  the  pylorus. 

Diagnosis. — Clinically  there  should  be  a  distinction  between  cases 
which  seem  to  be  those  of  pure  spasm  of  the  pylorus  with  only  relative 
or  temporary  stenosis  and  those  in  which  there  is  a  true  hypertrophy 
with  stenosis  of  the  pylorus  of  congenital  origin.  In  simple  spasm 
there  is  persistent  vomiting,  retention  of  stomach  contents,  steady 
emaciation,  and  constipation.  There  may  be  no  peristalsis  and  the 
pylorus  is  not  distinctly  felt.  If  indeed  it  is  palpable,  it  is  only  so 
as  a  very  small,  indistinct  nodule.  There  are  one  or  two  daily  stools 
which  contain  a  very  small  amount  of  milk  fseces.  In  hypertrophic 
stenosis  all  the  above  symptoms  are  present  to  an  aggravated  degree. 
There  is  marked  visible  peristalsis,  the  constipation  is  complete,  the 
stools  show  no  milk  fseces,  only  bile-stained  mucus.  The  pylorus  is 
distinctly  palpable. 

Congenital  conditions,  such  as  real  growths  of  the  pylorus  or 
atresia  of  the  pylorus,  are  exceedingly  rare,  and  can  scarcely  be 
brought  into  consideration  in  connection  with  conditions  which  are 
considered  in  this  paper.  The  symptoms  in  congenital  atresia  and 
growths  which  completely  obstruct  the  pylorus  must  come  on  imme- 
diately after  birth,  and  are  rapidly  fatal,  unlike  the  conditions  in 
which  the  symptoms  appear  some  time  after  birth.  Congenital 
stenosis  of  the  jejunum  or  duodenum  may  be  confounded  with  that 
of  stenosis  of  the  pylorus,  if  the  congenital  atresia  of  the  gut  is 
situated  high  and  near  the  pylorus.  There  may  then  be  a  series  of 
symptoms  on  the  part  of  the  stomach  indistinguishable  from  those 
of  pyloric  obstruction. 

Pure  pyloric  spasm,  I  feel,  may  well  occur  and  does  occur  with 
very  slight  hypertrophy  of  the  pylorus,  giving  rise  to  only  a  limited 
form  of  stenosis.  Ibrahim  doubts  the  existence  of  pure  pyloric  spasm, 
but  I  have  tried  to  show  that  it  does  occur,  and  this  also  in  quite  a 


51(3  DISEASES    OF    THE   STOMACH  AND   INTESTINES. 

percentage  of  cases;  more  especially  is  this  so  in  those  cases  of  per- 
sistent vomiting  in  which  there  is  sudden  or  gradual  cessation  of 
symptoms  upon  the  inauguration  of  correct  diet  and  feeding.  I 
think,  in  considering  the  question  as  to  whether  a  spasm  or  severe 
form  of  stenosis  is  present,  one  of  the  most  useful  clinical  guides  is 
the  amount  and  quantity  of  the  stools. 

If  in  a  given  case  the  stools  consist  mostly  of  bile-stained  mucus 
and  very  little  fsecal  matter,  in  spite  of  the  ingestion  of  an  ideal  food, 
such  as  breast  milk,  we  are  driven  to  the  conclusion  of  the  presence 
not  only  of  spasm  of  the  pylorus,  but  also  of  narrowing  and  stenosis 
of  high  degree.  If,  in  spite  of  vomiting  at  every  feeding,  peristalsis 
and  even  a  palpably  contracted  gut  in  the  region  of  the  pylorus, 
there  is  one  or  two  stools  daily  containing  some  milk  faeces,  we  must 
feel,  as  in  certain  of  my  cases  which  at  times  appeared  hopeless,  that 
the  stenosis  at  the  pylorus  is  not  of  high  degree,  and  that  the  spasm 
relaxes  at  times  and  allows  a  certain  amount  of  food  to  pass  and 
nourish  the  patient.  It  is  in  most  of  these  cases  that  we  can  feel  that 
the  ultimate  outcome  will  be  favorable,  no  matter  how  exasperating 
present  symptoms  appear  to  be. 

Prognosis. — The  ultimate  fate  of  these  eases  is  extremely  inter- 
esting in  view  of  the  recent  contention  from  some  quarters  that  as 
soon  as  the  diagnosis  of  hypertrophic  congenital  stenosis  is  made 
the  surgeon  must  interfere  in  behalf  of  the  infant.  I  have  tried  to 
show  that  a  large  number  of  cases  are  really  spasm  cases,  and  will 
eventually  recover  on  internal  therapy.  Persistent  trial  of  feeding, 
the  most  diverse,  will  eventually  result  in  overcoming  the  condition. 

As  to  the  ultimate  prognosis  of  true  hypertrophic  stenosis  of  the 
pylorus  my  own  feeling  is  that  there  can  be  no  absolute  statement  to 
fit  all  cases.  The  majority,  I  am  certain,  will  recover  under  per- 
sistent attempts  at  feeding,  and  from  my  own  experience  ultimate 
recovery  by  internal  management  is  not  impossible  in  cases  which  it 
would  seem  must  be  operated  upon.  It  is  the  exceptional  case  which 
will  come  under  the  notice  of  the  surgeon.  According  to  some  writers 
fully  85  per  cent,  of  the  cases  of  spasm  or  stenosis  will  recover  with- 
out resort  to  the  knife.  My  own  experience,  which  is  quite  large, 
seems  to  support  this  contention. 

Treatment. — T  shall  consider  for  conciseness:  (a)  Feeding;  (h) 
mechanical  means  of  therapy;  (c)  drugs;  and  (d)  operative  means. 

Feeding. — In  a  given  case  of  hypertrophic  stenosis  or  of  congen- 
ital spasm  the  feeding  is  undoubtedly  by  far  the  most  important 
element  in  the  treatment.  Breast  feeding  is  the  ideal  method  of 
feeding  these  cases,  but  not  every  breast  will  be  found  adapted  to 
the  infant.  The  breast  is  given  at  long  intervals  and  short  nursings. 
Many  infants  who  have  not  improved  on  a  given  breast,  or  to  whom 


DISEASES   OF    THE   STOMACH  AND   INTESTINES.  517 

a  breast  is  not  available,  will  be  tided  over  their  illness  by  some  of  tbe 
many  and  diverse  forms  of  substitutes  for  the  breast  at  command  of 
the  physician. 

I  do  not  think  any  artificial  food  is  ideal,  and  no  one  is  a  panacea 
in  this  condition.  Some  insist  that  the  food  contain  a  minimal  fat, 
and  I  have  seen  many  cases  recover  on  a  food  which  all  pediatrists 
agree  is  the  most  unsuitable  in  the  long  run  under  ordinary  con- 
ditions. In  other  words,  though  this  condition  seems  in  a  certain 
proportion  of  cases  to  have  been  inaugurated  by  some  error  in  diet, 
there  is  no  royal  road  to  the  feeding.  In  artificial  as  in  breast  feed- 
ing the  method  must  presuppose  small  amounts  at  each  feeding,  at 
long  or  short  intervals,  as  the  case  may  be. 

Mechanical. — Mechanical  means  of  therapy  include  the  applica- 
tion of  warm  cataplasms  of  flax  seed  and  hops,  or  dry  warmth,  stomach 
washing,  and  enteroclysis.  Stomach  washing  is  in  some  cases,  when 
the  infant  is  in  a  weakened  condition,  an  exhausting  procedure, 
though  some  observers,  such  as  Pfaundler  and  Feer,  laud  its  use 
highly.  It  may  be  tried  at  first  and  if  no  immediate  relief  result  it 
should  be  suspended. 

Gavage. — I  have  used  gavage  with  some  degree  of  success  in  cer- 
tain cases  and  recently  Saunders  has  had  markedly  favorable  results 
with  this  procedure.  By  it  fixed  amounts  of  food  are  introduced  into 
the  stomach  at  intervals. 

Enemata  are  useful  in  the  form  of  enteroclysis  of  small  amounts 
of  normal  saline  solution  to  maintain  nutrition.  They  are  given 
several  times  daily. 

Drugs. — Heubner  advises  opiates,  others  derivatives  of  opium,  in 
very  small  amounts  to  quiet  the  spasm  of  the  pylorus  and  adjacent 
stomach  wall.  Heubner  uses  the  tincture.  In  most  of  my  cases  no 
opiate  was  resorted  to,  and  in  only  one  was  it  given,  and  then  only 
after  improvement  was  well  inaugurated  and  only  in  exceedingly 
small  doses  and  at  desultory  intervals.  I  have  found  but  temporary 
benefit  from  the  administration  of  citrate  of  soda,  or  soda  and 
pancreatin. 

Operative  Therapy. — An  operation  such  as  is  proposed  for  the 
relief  of  congenital  hypertrophic  stenosis  of  the  pylorus  presupposes 
great  technical  skill  on  the  part  of  the  surgeon.  The  published  mor- 
tality under  the  knife  varies  from  50  per  cent,  to  75  per  cent,  and 
this  does  not  give  us  any  idea  of  the  cases  which  have  in  the  hands  of 
some  surgeons  given  a  higher  mortality.  The  operation  of  selection 
is  posterior  gastro-enterostomy. 

Acute  Gastro-enteric  Infection  (including  Cholera  Infantum) 
{Summer  Diarrhoea;  Acute  Gastro-enteric  Infection). — Acute  gastro- 
enteric infection  is  a  form  of  intestinal  disturbance  usually  accom- 


518  DISEASES    OF    THE   STOMACH   AND   INTESTINES. 

panied  bj  gastric  symptoms.  It  is  prevalent  in  the  summer,  but 
may  also  occur  during  tbe  winter  months.  Bottle-fed  infants  are 
more  subject  to  the  affection,  although  it  occasionally  attacks  infants 
at  the  breast.  In  institutions  epidemics  of  the  disease  occur  in 
breast-fed  infants.  In  large  cities  more  than  one-half  the  deaths 
among  infants  under  the  age  of  twelve  months  are  caused  by  summer 
diarrhoea.  In  Paris,  Chaterinkoff  found  that  of  20,000  children 
dying  of  gastro-intestinal  disorders,  fully  three-fifths  were  bottle-fed. 
This  high  rate  of  the  mortality  of  bottle-fed  infants,  as  compared  with 
that  of  breast-fed  infants,  is  not  alone  due  to  the  difference  in  the 
nature  of  the  food;  no  matter  how  carefully  it  is  handled  before  it 
reaches  the  infant,  milk  passes  through  many  channels,  and  in  each 
of  these  it  is  exposed  to  infection.  The  intense  heat  of  summer  also 
favors  the  increase  of  infectious  agents. 

Etiology  and  Classification. — The  various  forms  of  acute  gastro- 
intestinal infection  may  be  divided  into  those  whose  source  of  infec- 
tion lies  outside  the  body  (ectogenous)  and  those  in  which  the  elements 
of  infection  are  pre-existent  in  the  body  (endogenous).  This  classi- 
fication (Escherich)  is  both  practical  and  in  accordance  with  the 
results  of  recent  study. 

In  the  first  class  are  included  the  diarrhceas  of  toxic  origin  and 
cholera  infantum;  in  the  second  are  included  the  diarrhoeas  which 
are  caused  by  varieties  of  bacteria  pre-existent  in  the  intestine,  but 
which,  in  the  opinion  of  Booker,  Escherich,  and  Marfan,  may  under 
favorable  conditions  increase  to  enormous  numbers  and  become  viru- 
lent. According  to  Booker,  no  one  sjDecific  micro-organism  is  the 
essential  cause  of  acute  summer  diarrhoea,  Escherich  has  shown 
that  the  coli  group  may  under  certain  conditions  become  virulent. 
Of  the  bacteria  which  are  found  in  certain  forms  of  gastro-intestinal 
infection,  the  Streptococcus  enteritidis  seems  to  have  attracted  the 
greatest  atttention,  Booker  first  insisted  on  the  importance  and  pecu- 
liar role  of  this  micro-organism.  He  found  these  streptococci  in 
great  numbers  not  only  in  the  stools  of  infants  suffering  from  acute 
summer  diarrhoea,  but  also  in  the  walls  of  the  gut  and  in  the  various 
organs  of  the  body.  Escherich  and  his  pupils,  Libman  and  Hirsch, 
have  confirmed  the  results  of  Booker.  Escherich  regards  the  Strep- 
tococcus enteriditis  as  an  ectogenous  infection.  The  udder  of  the 
cow  may  be  the  source  of  this  micro-organism.  Marfan  and  Booker 
are  also  inclined  to  believe  that  streptococci  are  able  under  certain 
conditions  to  increase  in  number  and  virulence  and  that  they  are  one 
of  the  endogenous  forms  of  infection  by  a  micro-organism  normally 
present  in  the  gut.  Among  the  other  bacteria  found  in  enormous 
numbers  in  the  movements  of  infants  and  children  suffering  from 
acute  gastro-entcric  infection  are  the  Bacillus  pyocyaneus  (Kosseland 


DISEASES   OF    THE   STOMACH  AND   INTESTINES.  519 

Baginsky),  Proteus  vulgarus  (found  bj  Booker  in  clioleriform  diar- 
rhoea), and  the  proteolytic  bacteria. 

The  second  class  comprises  peptonizing  bacteria,  such  as  the  Ba- 
cillus subtilus,  Bacillus  mesentericus  vulgatus,  and  Tyrotrix  tenuis. 
These  peptonizing  bacteria  are  not  found  in  the  gut  or  stools  of  the 
breast-fed  infant  either  when  in  good  health  or  sick.  We  may  thus 
classify  all  diarrhceas  of  acute  gastro-enteric  infection  as  follows : 

1.  Those  due  to  improper  food,  or  the  so-called  mechanical  irri- 
tative diarrhoeas  (Booker). 

2.  The  infectious  forms  (endogenous  and  ectogenous).  This 
class  would  include  the  toxic  diarrhoeas  of  some  authors. 

ISTot  only  the  food  and  the  bacteria,  but  also  certain  changes  in 
the  intestine  play  an  important  role  in  acute  gastro-enteric  infection. 

Morbid  Anatomy. — Stomach  and  Intestines. — Booker  has  described 
a  superficial  loss  of  the  epithelium  of  the  stomach  and  gut,  as  a  con- 
stant lesion  in  all  fatal  cases  of  gastro-enteric  infection.  It  may  be 
intact  in  some  places  and  destroyed  or  eroded  in  others.  The  mucous 
membrane  of  the  jejunum  and  duodenum  may  show  less  denudation 
than  other  parts  of  the  gut.  The  epithelial  layer  of  the  mucosa  is  infil- 
trated with  leucocytes  in  diffuse  areas  or  nests.  The  infiltration  may 
push  the  epithelial  layer  upward.  The  mucosa  itself  is  infiltrated 
with  polynuclear  and  mononuclear  leucocytes  to  a  varying  extent. 
The  mucosa  shows  superficial  or  deep  ulcerations  involving  the  crypts 
or  villi.  Heubner  has  described  a  form  of  necrosis  which  chiefly 
affects  the  epithelial  structure  without  involving  the  deep  mucosa. 
This  occurs  in  cholera  infantum.  Booker  also  describes  a  bronchitis 
and  a  form  of  bronchopneumonia  which  are  quite  constantly  found 
in  fatal  cases.     Hemorrhages  into  the  lung  tissue  are  common. 

Kidneys. — In  the  kidneys  there  is  necrosis  of  epithelium  in  the 
convoluted  and  irregular  tubules  (Booker). 

Liver. — The  liver  shows  fatty  degeneration  and  necrosis  of  the 
liver-cells. 

Lymph-nodes. — The  lymph-nodes  show  focal  necrosis. 

The  Role  of  the  Bacteria. — Booker  has  demonstrated  that  no  bac- 
teria are  found  in  the  mucosa  of  the  intestine  if  the  superficial  epi- 
thelium is  intact.  If  there  is  a  lesion  of  continuity  of  the  superficial 
layer,  the  bacteria  invade  the  mucosa  in  large  numbers.  There  is 
reason  to  believe  that  the  toxins  generated  by  the  bacteria  in  the  gut 
cause  the  superficial  erosions  and  prepare  the  way  for  invasion  of 
the  lymph-channels  and  bloodvessels.  Bacteria  are  not  always  found 
in  the  lesions,  but  as  a  rule  the  ulcerations  of  the  mucosa  show  vast 
numbers.  Booker  found  bacteria  in  cultures  taken  from  the  solid 
organs  and  blood,  thus  confirming  what  Czerny  and  Mozer  found  to 


520  DISEASES   OF   THE   STOMACH  AND   INTESTINES. 

be  the  case  during  life.  The  lungs  especially  showed  large  numbers 
of  bacilli  and  cocci. 

Symptoms, — In  the  mild  form  of  gastro-enteric  infection  the  infant 
is  restless  and  cries  at  intervals  because  of  colicky  pains.  It  may 
previously  have  been  in  good  health,  but  with  the  advance  of  these 
symptoms  there  will  also  be  noticed  a  slight  febrile  movement  and  a 
disinclination  to  take  the  bottle  or  breast.  Vomiting  occurs  after 
feeding,  the  rejected  contents  of  the  stomach  being  curdled  and  having 
a  marked  acid  odor.  In  mild  cases  the  vomiting  is  usually  not  severe. 
It  may  be  repeated  three  or  four  times  in  the  twenty-four  hours.  The 
movements  are  at  first  normal;  they  afterward  become  frequent  and 
contain  whitish  curds  or  greenish  and  white  curds,  are  more  fluid  than 
is  normal,  and  may  have  a  very  offensive  odor.  In  mild  cases  there 
may  be  only  two  or  three  such  movements  in  the  twenty-four  hours 
or  they  may  number  six  or  more.  Later,  the  fever  also  becomes  more 
marked,  the  temperature  sometimes  mounting  as  high  as  103°  F. 
(39.4°  C).  If  the  feeding  is  continued,  the  vomiting  persists.  The 
infant  shows  little  or  no  prostration. 

In  severe  cases  the  vomiting  is  marked  from  the  outset.  The 
infant  not  only  vomits  its  regular  food,  but  will  also  often  vomit  all 
fluid  that  is  taken  into  the  stomach.  The  diarrhoea  is  also  more 
severe  than  in  the  mild  forms.  The  movements  are  at  first  yellow 
or  greenish  and  contain  white  curds,  but  as  the  disease  advances  they 
become  more  fluid,  until  in  very  severe  cases  only  a  greenish  malo- 
dorous liquid  containing  small  particles  of  mucus  and  faecal  matter 
is  voided.  The  infant  has  a  febrile  movement  which  varies  from 
101°  to  103°  F.  (38.8°  to  39.4°  C),  and  there  is  marked  prostra- 
tion. In  the  acute  forms  of  gastro-enteric  infection  there  is  consid- 
erable loss  of  weight;  the  infant  becomes  pale  and  languid,  and  the 
pulse  is  rapid  and  weak ;  the  number  of  daily  evacuations  may  reach 
twenty.  In  some  cases  the  straining  causes  a  descent  of  the  lower 
part  of  the  rectum,  and  the  movements  contain  a  slight  amount  of 
bloody  mucus.     The  odor  of  the  evacuation  may  not  be  offensive. 

If  the  patient  improves,  the  symptoms  retrograde — the  vomiting 
becomes  less  frequent,  the  stools  more  fsecal  in  character  and  less 
numerous,  and  the  fever  subsides.  If,  on  the  other  hand,  the  symp- 
toms progress,  the  movements  not  only  continue  frequent  and  fluid, 
but  also  blood  and  particles  of  mucus  are  mingled  with  the  fsecal  mat- 
ter. The  vomiting  may  cease  entirely.  The  infant  loses  in  weight 
steadily;  the  movements  are  small  and  passed  with  tenesmus;  the 
patient  passes  into  the  subacute  stage.  In  some  cases  there  is  colic ; 
the  infants  are  restless  or  pass  into  an  apathetic  condition.  Little 
urine  is  passed,  and  in  the  majority  of  cases  of  mild  or  severe  gastro- 
enteric infection  albumin  is  present.     It  rarely  amounts  to  more  than 


DISEASES   OF    TEE   STOMACH  AND   INTESTINES.  521 

a  trace.  In  severe  cases  there  are  leucocytes  and  epithelial,  hyaline, 
and  blood-casts  in  the  urine ;  sometimes  in  addition  a  few  blood-cells 
are  found. 

In  the  subacute  forms  of  gastro-enteric  infection  which  last  for 
more  than  a  week,  bronchopneumonia  may  be  a  complication.  This 
form  of  bronchopneumonia  is  described  in  the  section  on  Pneumonia. 
In  some  cases  it  is  of  short  duration,  in  others  persistent.  Broncho- 
pneumonia with  slowly  resolving  areas  of  consolidation  in  the  lung 
is  the  type  met  with. 

Course  and  Prognosis. — The  prognosis  of  the  mild  forms  is  good, 
if  proper  measures  are  adopted.  The  severe  forms  are  exceedingly 
fatal  in  summer.  The  mortality  varies  with  the  environment.  In 
the  crowded  tenements  of  large  cities  and  in  unhygienic  surroundings 
the  mortality  is  great,  as  is  also  the  case  in  institutions  and  hospitals. 
In  private  practice  the  isolation  of  the  patient  and  special  nursing 
reduce  the  mortality  to  a  minimum  by  preventing  reinfection.  Rein- 
fection is  caused  by  lack  of  care  in  handling  the  diapers  and  in  pre- 
paring the  food,  by  giving  improper  food,  and  by  placing  a  number 
of  cases  in  the  same  room.  There  can  be  no  question  that  in  hospitals 
patients  are  affected  unfavorably  by  proximity  to  other  patients  suf- 
fering with  the  same  disease.  ISTo  matter  how  careful  the  nursing 
under  such  circumstances,  reinfection  cannot  be  prevented.  Also, 
perfect  cleanliness  is  not  attainable  in  hospitals  as  in  private  practice. 

Treatment. — See  under  Cholera  Infantum. 

Cholera  Infantum. — Cholera  infantum  is  the  severest  form  of 
summer  diarrhoea  prevalent  among  infants.  It  is  believed  that  it 
has  a  specific  origin,  but  this  has  not  as  yet  been  demonstrated. 
Cholera  infantum  does  not  occur  so  frequently  as  has  been  hitherto 
supposed.  Of  hundreds  of  cases  of  gastro-enteric  infection  of  the 
acute  variety  which  come  under  my  care  yearly,  only  a  few  can  be 
called  typical  of  this  form  of  infectious  diarrhoea.  These  cases  occur 
for  the  most  part  in  weakly  bottle-fed  infants.  Breast-fed  infants 
may  occasionally  be  affected,  especially  in  hospitals. 

Symptoms. — The  infants  as  a  rule  have  been  suffering  from  a 
mild  diarrhoea.  Following  a  slight  febrile  movement,  vomiting  and 
diarrhoea  of  a  severe  and  exhausting  character  set  in.  The  bowel 
movements  are  frequent,  but  contain  very  little  fsecal  matter  after  the 
first  few  have  been  passed.  They  are  at  first  greenish,  afterward 
becoming  watery,  resembling  barley-water;  they  contain  but  a  few 
flocculi  of  mucus,  and  may  not  have  much  odor.  The  vomiting  is 
incessant.  First  the  stomach  contents  are  vomited,  and  finally  a 
greenish  fluid.  Within  a  few  hours  the  infant  is  reduced  to  a  condi- 
tion of  great  prostration.  The  loss  of  weight  is  marked,  even  in  the 
first  twenty-four  hours.     The  skin  on  the  thighs  is  wrinkled. 


522  DISEASES    OF    IKE   STOMACH  AND   INTESTINES. 

The  face  and  trunk  are  pale  and  tlie  face  is  drawn.  There  is 
fever  to  a  marked  degree  (101°-103°  F.,  38.3°-39.4°  C),  and  the 
pulse  is  rapid  and  thready.  Toward  the  close  the  movements  are 
passed  involuntarily.  The  whole  picture  is  that  of  a  choleriform 
disease.  As  the  fatal  issue  approaches  the  eyes  become  sunken  and 
glassy,  the  fontanelle  is  depressed,  and  the  mouth  is  open.  The  con- 
dition described  elsewhere  as  hydrocephaloid  sets  in.  Convulsions 
and  a  rise  of  temperature  (105="'to  107°  F.,  40.5°  to  41.6°  C.)  pre- 
cede the  fatal  issue. 

Occurrence. — These  severe  choleriform  diarrhoeas  resemble  Asiatic 
cholera  very  closely,  and  should  be  sharply  differentiated  from  severe 
forms  of  gastro-enteric  infection.  They  occur  in  bottle-fed  infants 
under  the  age  of  two  years,  and  chiefly  in  the  months  of  July  and 
August.  Heat  and  infected  food  are  the  main  etiological  factors.  A 
diarrhoea  of  a  mild  type  is  the  forerunner  in  the  majority  of  cases. 
These  cases  are  not  so  frequent  to-day  as  they  were  in  the  days  when 
infants  were  fed  with  decomposed  milk  containing  bacterial  toxins. 
This  form  of  diarrhoea  must  therefore  be  looked  upon  as  a  purely 
ectogenous  infection. 

Duration  and  Prognosis. ^ — The  prognosis  in  the  majority  of  cases 
of  cholera  infantum  is  grave.  The  disease  is  an  exceedingly  fatal 
one,  occurring  as  it  does  for  the  most  part  in  infants  fed  on  the  bottle 
whose  general  condition  is  poor.  It  lasts  for  from  twenty-four 
hours  to  two  or  three  days.  The  rapidity  of  the  development  of  the 
symptoms  and  of  the  fatal  results  precludes  the  possibility  of  any 
complications  other  than  those  due  to  the  great  drain  on  the  system. 
The  condition  of  hydrocephaloid  is  hardly  a  complication ;  it  is  a  ter- 
minal set  of  cerebral  symptoms.  Sclerema,  mentioned  by  some 
authors,  I  have  not  met  in  true  cholera  infantum;  it  is  seen  in  the 
terminal  stage  of  acute  forms  of  gastro-enteric  infection.  This  form 
of  sclerema  affects  the  thighs  at  the  upper  and  inner  part.  It  is 
described  in  the  section  devoted  to  that  subject. 

Kjelberg,  Felsenthal,  Bernard,  Morse,  and  the  writer,  found 
albumin  and  casts  in  the  urine  of  children  suffering  from  all-  forms  of 
gastro-enteric  infection,  acute  and  subacute,  including  cholera  in- 
fantum. 

Morse  as  well  as  the  author  found  that  the  urine  was  concentrated 
and  contained  hyaline,  granular,  and  epithelial  casts,  with  leucocytes 
and  blood  and  blood-casts.  The  albumin  is  rarely  present  to  a  marked 
degree.  It  is  a  trace  or  a  distinct  reaction.  The  urine  is  suppressed 
in  severe  cases,  and  lessened  in  quantity  in  others.  In  some  cases 
of  the  severe  types  there  is  slight  oedema  of  the  subcutaneous  tissues, 
especially  on  the  inner  part  of  the  thighs,  the  legs,  and  dorsum  of  the 
foot.     We  are  not  in  a  position  to  trace  any  close  relationshij?  between 


DISEASES    OF    THE   STOMACH  AND    INTESTINES.  523 

the  general  symptoms  and  the  disturbances  of  the  kidney.  The 
toxa?mia  in  this  disease,  causing  as  it  does  vomiting  and  nervous  symp- 
toms, masks  the  nephritic  symptoms  if  they  are  present. 

Diagnosis. — The  diagnosis  of  acute  gastro-enteric  infection  is  not 
difficult.  There  are,  hov^ever,  many  infectious  diseases,  the  onset  of 
which  it  closely  resembles.  Scarlet  fever,  for  example,  begins  with 
vomiting,  and  in  some  cases  with  diarrhoea.  There  is  a  form  of 
grippe  which  in  its  onset,  with  vomiting  and  diarrhoea,  closely  resem- 
bles an  attack  of  gastro-enteric  disease.  In  fact,  these  symptoms  may 
persist  in  the  course  of  the  former  affection. 

The  physician  should  not  be  satisfied  with  a  history  of  gastro- 
enteric symptoms,  but  should  carefully  examine  the  skin,  throat,  and 
chest  at  every  visit.  In  the  severe  forms  of  diarrhoea  a  small  particle 
of  the  movement  may  be  spread  on  a  cover-glass  and  examined  for 
an  excessive  number  of  streptococci.  In  mild,  protracted  forms  of 
diarrhoea  we  should  not  fail  to  make  a  Widal  test  of  the  blood  and  a 
count  of  the  leucocytes,  to  eliminate  the  possibility  of  typhoid  fever. 
This  will  especially  be  indicated  in  cases  in  which  there  is  enlarge- 
ment of  the  spleen. 

Treatment  of  Acute  Gastro-enteric  Infection  and  Cholera  Infantum. — 
Prophylaxis. — The  nursing  bottles  when  emptied  by  the  infant  should 
be  filled  with  a  saturated  solution  of  sodium  bicarbonate,  allowed  to 
stand  for  a  few  hours,  and  then  carefully  washed  inside  and  out  with 
a  bristle  brush.  The  nipples  should  be  sterilized  daily.  The  nurse  or 
mother,  after  attending  to  the  diapers  of  the  infant,  should  carefully 
cleanse  the  hands  before  feeding  the  baby.  The  milk  should  be  diluted 
as  directed  in  the  section  on  Infant  Feeding,  pasteurized  or  sterilized, 
and  then  kept  on  ice  until  needed.  The  milk  should  be  fresh  and 
delivered  for  modification  within  a  few  hours  of  the  milking-time. 
The  nursing  should  be  conducted  at  stated  intervals.  If  there  is  a 
residue  in  the  nursing  bottle,  it  should  not  be  utilized  for  a  subse- 
quent nursing.  The  infant  is  given  a  full  bath  daily.  By  attend- 
ing to  all  these  details,  infection  of  the  food  and  of  the  infant  may 
be  avoided.  With  breast-fed  infants  prophylaxis  is  of  great  impor- 
tance. A  baby  at  the  breast  should  be  fed  at  regular  intervals.  The 
breast-nipples  should  be  washed  with  a  saturated  solution  of  boric 
acid  before  and  after  nursing.  The  baby  should  not  be  allowed  to 
nurse  a  breast  with  a  fissured  nipple.  The  milk  of  such  a  breast  is 
pumped  off,  and  an  attempt  is  made  to  heal  the  nipple  in  the  manner 
elsewhere  described.  If  there  is  caking  of  the  breast,  the  condition 
should  be  remedied  before  the  infant  is  allowed  to  nurse.  Abun- 
dance of  fresh  air  and  bathing  are  indicated  in  these  infants  as  in 
bottle-fed  infants. 

SicJc  Infants. — As  soon  as  a  baby  shows  signs  of  even  mild  dys- 


524  DISEASES    OF    THE   STOMACH  AND   INTESTINES. 

pepsia  or  gastro-enteric  infection  the  milk  should  be  discontinued,  a 
simple  cathartic  given,  and  the  infant  kept  for  twenty-four  hours  on  a 
solution  of  egg-albumin.  Vomiting  which  has  occurred  only  once  or 
twice  does  not  call  for  active  treatment,  as  it  will  disappear  as  soon 
as  the  milk  is  discontinued.  After  the  bowels  have  moved,  if  the 
infant  shows  no  exacerbation  of  symptoms  feeding  should  be  resumed 
cautiously.  In  this  way  a  severe  illness  can  be  averted.  If  the  food 
is  not  suitable,  causing  signs  of  dyspepsia  such  as  colic,  it  should  be 
changed  if  possible,  else  severer  symptoms  may  result.  If  in  spite 
of  all  precautions  an  attack  develops,  the  patient  should  be  treated 
on  the  following  lines : 

1.  The  food  is  stopped  and  another  of  a  safe  character  substituted. 

2.  The  toxins  are  eliminated  and  the  strength  of  the  patient  sup- 
ported by  the  so-called  mechanical  methods. 

3.  Drugs  are  used  to  abate  the  symptoms  and  support  the  strength 
of  the  patient. 

The  milk,  whether  of  the  breast  or  bottle,  is  discontinued.  The 
infant  is  given  a  solution  of  albumin-water,  acorn-cocoa,  or  beef -juice 
expressed  and  diluted  with  barley-water.  A  baby  can  be  kept  for 
days  upon  these  mixtures  without  any  danger  of  reducing  the  strength. 

According  to  Czerny,  100  c.c.  of  breast  milk  are  equivalent  to 
61  calories;  100  c.c.  of  the  white  of  egg  are  equal  to  75.1  calories. 
The  white  of  one  egg  weighs  about  30  grammes ;  therefore  the  white 
of  an  egg  is  equal  to  about  25  calories.  It  is  digestible,  and  is  well 
borne  by  infants.  Albumin-water  may  be  used  alternately  with  the 
solution  of  acorn-cocoa  or  beef -juice  and  barley-water.  To  older 
children  we  may  sometimes  have  difficulty  in  administering  albumin- 
water  or  acorn-cocoa.  Under  such  conditions,  when  the  acute  stage 
is  passed,  I  frequently  resort  to  a  dextrinized  gruel  or  the  so-called 
Liebig's  soup  mixture  which  Keller  devised. 

The  cathartic  given  at  the  onset  should  be  castor  oil  or  calomel,  ^ 
grain  (0.03)  doses  twice  or  three  times  a  day.  Infants  who  are  vom- 
iting are  given  calomel  in  preference  to  castor  oil. 

Vomiting. — If  the  vomiting  is  not  severe  and  the  case  is  under 
treatment  from  the  onset,  it  is  best  not  to  wash  out  the  stomach  at 
once.  It  often  happens  that  the  vomiting  ceases  as  soon  as  the  regular 
food  is  stopped.  If,  however,  the  vomiting  persists  for  twenty-four 
hours,  we  proceed  to  wash  out  the  stomach.  If  the  vomiting  con- 
tinues after  this,  it  is  either  toxic  or  may  in  rare  cases  be  due  to 
some  other  causes.  As  a  rule,  it  ceases  after  one  irrigation  of  the 
stomach. 

Diarrhoea. — The  diarrhoea  is  controlled  by  irrigation  of  the  gut. 
The  rectum  and  gut  are  washed  out  in  those  cases  in  which  the  diar- 
rhoea is  not  only  persistent,  but  progressive.     The  object  in  washing 


DISEASES    OF    THE   STOMACH   AND    INTESTINES.  525 

out  the  lower  bowel  is  two-fold:  (a)  to  remove  any  residue  of  fseces 
that  may  have  collected  in  the  lower  bowel  and  rectum,  and  to  stimu- 
late peristalsis  and  thereby  favor  evacuation  from  above;  (&)  to 
stimulate  the  heart  and  add  to  the  body  an  amount  of  normal  solu- 
tion to  compensate  for  the  drain  caused  by  the  diarrhoea.  The  Can- 
tani  normal  salt  solution  is  utilized  in  the  manner  described. 

The  rectal  enemata  are  given  under  a  pressure  obtained  by  an 
elevation  of  at  most  two  feet  from  the  bed.  A  temperature  of  107° 
to  110°  F.  (40.5°  to  43.3°  C.)  is  the  best  and  most  stimulating  in 
these  cases.  Fully  a  quart  of  water  is  thrown  into  the  rectum  in 
half-pint  portions.  As  the  half-pint  flows  in,  the  funnel  on  the  rectal 
tube  is  disconnected  and  the  contents  of  the  bowel  are  allowed  to 
escape.  Another  portion  is  then  allowed  to  flow  into  the  bowel.  The 
water  will  sometimes  escape  alongside  of  the  tube.  This  is  rather  a 
favorable  sign,  being  significant  of  the  contractile  powers  of  the  gut 
and  abdominal  walls.  Only  two  enemata  daily  are  necessary,  even 
in  severe  cases.  As  the  diarrhoea  and  symptoms  subside  we  reduce 
the  number  of  enemata  to  one,  finally  discontinuing  them  entirely 
as  the  infant  improves. 

It  sometimes  happens  that  after  a  few  days  the  enemata  are  fol- 
lowed by  movements  containing  blood  and  mucus,  the  tenesmus  being 
aggravated.  In  these  exceptional  cases  an  enema  must  be  given  only 
every  other  day,  and  the  effect  on  the  rectal  discharges  watched.  By 
stopping  the  enemata  altogether  it  can  be  determined  whether  the  dis- 
charges of  mucus  and  blood  are  caused  by  the  therapy  or  the  disease. 

Hypodermoclysis. — The  injection  of  normal  salt  solution  under 
the  skin  is  indicated  only  in  the  severe  cases  in  which,  as  in  cholera 
infantum,  the  course  of  the  disease  is  rapid  and  the  prostration  ex- 
treme. Personal  experience  rather  discourages  the  employment  of 
large  injections  by  this  method.  I  have  seen  two  cases  of  infection 
by  the  Bacillus  capsulatus  aerogenes  (Welch)  following  hypoder- 
moclysis. These  occurred  through  the  use  of  saline  solution  evidently 
insufficiently  sterilized,  and  which  had  probably  been  allowed  to  stand 
before  being  used.  In  a  third  case  hemorrhages  over  large  areas 
occurred  at  the  point  of  the  injection  of  the  salt  solution.  These 
injections  are  also  very  painful. 

Because  of  these  dangers  and  disadvantages  the  subcutaneous 
injections  of  salt  solutions  should  be  utilized  as  a  last  resource  in 
desperate  cases.  Small  rather  than  large  amounts  of  fluid  should  be 
injected  subcutaneously.  The  salt  solution  for  the  hypodermoclysis 
is  that  of  Cantani.  It  should  be  sterilized  at  a  temperature  of  212° 
F.  (100°  C.)  for  at  least  an  hour,  to  kill  sporulated  bacteria  if 
possible. 

Baths. — In  all  cases,  whether  with  or  without  elevation  of  tem- 


526  DISEASES   OF    THE   STOMACH  AND   INTESTINES. 

perature,  the  benefit  obtained  from  warm  baths  cannot  be  overesti- 
mated. In  cases  of  great  i^rostration  a  bath  at  108°  F,  (42.2°  C.) 
for  fire  minutes  is  stimulating  to  the  nervous  centres  and  is  followed 
in  many  cases  by  diminution  of  the  apathy  and  an  apparent  reduction 
of  the  effects  of  toxaemia.  If  the  temperature  rises  above  103°  F. 
(39.4°  C),  sponging  with  water  at  80°-85°  F.  (26.6°-29.4°  C-.) 
is  all  that  is  needed.  This  should  not  be  done  oftener  than  once  in 
every  three  hours. 

Alcohol. — Of  late  years,  alcohol  is  given  less  and  less  in  cases  of 
acute  gastro-enteric  infection.  In  these  cases  there  is  a  special  intol- 
erance of  the  stomach  and  also  of  the  economy  to  alcohol.  Infants 
after  taking  it  for  twenty-four  hours  will  become  stupid,  apathetic,  and 
exhibit  a  constant  retching  if  they  do  not  vomit.  This  appears  to  be 
due  more  to  the  effect  of  the  alcohol  locally  on  the  stomach  and  also 
systemically  than  to  toxaemia  of  the  disease.  I  therefore  deprecate 
the  use  of  alcohol  except  in  extreme  cases,  when  whiskey  is  given  in 
small  doses  at  short  intervals. 

Strychnine.- — Strychnine  is  useful;  grain  3^oo  (0.0002)  is  given 
to  an  infant  of  six  months,  and  grain  %oo  (0.0003)  to  older  infants 
every  three  hours. 

Atropine. — Atropine,  lately  advised  as  a  cardiac  stimulant  in 
these  cases,  especially  in  cholera  infantum,  is  of  questionable  utility, 
and  should  not  be  employed.  I  have  seen  grain  %5o  (0.0004)  give 
rise  to  constant  tremulous  and  convulsive  twitching. 

Resorcin. — If  the  vomiting  is  constant,  grain  -J  (0.008)  of  resor- 
cin  given  every  three  hours  is  a  safe  and  very  u&eful  remedy. 

Bismuth. — Bismuth  in  the  form  of  the  subcarbonate  is  the  only 
drug  useful  in  allaying  the  vomiting  and  the  tenesmus  of  the  bowel. 
Grains  ij  or  iij  (0.12  or  0.18)  are  given  in  powder  form  every  two 
or  three  hours. 

Opium. — Opium  in  any  form  has  fallen  into  disuse.  In  the 
severe  cases  it  is  dangerous,  and  may  increase  the  prostration ;  in  the 
milder  cases  its  use  is  justifiable  only  if  the  colicky  pains  are  exces- 
sive. The  milder  preparations  such  as  the  wine  and  the  camphorated 
tincture  are  of  value,  because  they  can  be  given  in  graduated  doses, 
and  the  effects  determined  more  exactly  than  can  be  done  with  the 
stronger  preparations. 

Salol.—Salol  in  grain  ^  (0.03)  doses  every  three  hours  may  be 
combined  with  the  bismuth  to  alla}^  the  colicky  pains. 

Tannigen. — Tannigen  is  a  useful  drug  in  the  chronic  forms  of 
intestinal  disease,  but  an  irritant  in  the  acute  forms. 

Colic. — Colic  has  been  mentioned  so  often  that  a  few  words  as  to 
the  treatment  may  not  be  out  of  place.  Passing  of  the  rectal  tube 
rarely  relieves  it.  A  small  rectal  enema  has  been  found  to  be  a  very 
effective  remedy. 


DISEASES   OF   THE   STOMACH  AND   INTESTINES.  527 

As  the  symptoms  improve  care  should  be  taken  not  to  return  to 
a  milk  diet  too  quickly.  The  milk  is  given  in  dilutions  and  is  steri- 
lized carefully.  Infants  in  an  enfeebled  condition  as  a  rule  bear  this 
form  of  milk  best,  since  it  is  not  apt  "to  be  irritating  to  the  gut.  When 
the  danger  is  past  any  form  of  milk  may  be  given — ravsr,  pasteurized, 
or  sterilized — care  being  taken  that  all  the  precautions  as  to  freshness, 
cleanliness,  and  proper  preparation  are  observed.  I  have  mentioned 
the  fact  that  before  returning  to  dilutions  of  milk  the  exhibition  of 
dextrinized  gruels  has  been  successful  with  very  weak  infants.  The 
malt,  the  cereal,  and  the  milk  acted  upon  by  the  ferment  contained  in 
these  mixtures  are  all  easily  digestible  and  assimilable,  and  promote 
increase  of  weight.  As  a  matter  of  course,  the  effect  of  the  gruel 
mixture  on  the  stomach  and  gut  should  be  carefully  studied. 

Whatever  methods  are  employed  in  the  treatment,  it  is  necessary 
to  avoid  the  error  of  overtreatment.  It  should  be  remembered  that 
hours  of  rest  do  more  than  hours  of  treatment.  Three-hour  intervals 
should  elapse  between  the  application  of  remedial  measures.  Fresh 
air  in  the  room  or  a  sojourn  of  a  few  hours  in  the  open  with  absolute 
quiet,  is  of  the  greatest  value  in  these  cases. 

Acute  and  Subacute  Enterocolitis  (Enteritis  Follicularis;  En- 
teric Catarrh). — Enterocolitis  is  peculiarly  a  diarrhoeal  disease  of 
infancy  and  early  childhood.  It  was  formerly  classified  as  a  form 
of  dysentery,  because  in  these  cases  the  movements  are  tinged  with 
blood  and  contain  mucus.  The  cases  are,  however,  of  a  milder  type, 
and  present  many  symptoms  foreign  to  true  dysentery. 

Etiology. — In  many  of  its  features  this  affection  resembles  acute 
and  subacute  gastro-enteric  infection.  It  is  prevalent  during  the 
summer  months.  It  occurs  in  infants  after  the  first  year  of  life,  and 
may  be  primary  or  follow  an  ordinary  dyspeptic  diarrhoea,  one  of  the 
exanthemata,  pertussis,  or  bronchopneumonia.  Booker  his  described 
the  great  number  of  streptococci  found  in  certain  of  these  cases.  Fink- 
elstein  and  Escherich  and  his  pupils  have  confirmed  these  results,  and 
have  in  addition  presented  the  view  that  these  diarrhoeas  are  infec- 
tious and  may  be  caused  by  bacteria  of  the  coli  group.  The  bacteria 
may  be  introduced  from  without,  or  the  coli  organism  in  the  gut  under 
certain  conditions  may  become  virulent.  With  reference  to  their 
origin,  these  cases  may  be  considered  as  bearing  a  relationship  to 
cases  of  true  dysentery,  from  which  with  our  present  imperfect  knowl- 
edge it  is  not  always  possible  to  distinguish  them. 

Morbid  Anatomy. — The  mucous  membrane  is  hypersemic  and 
swollen ;  in  cases  of  long  duration  the  mucosa  is  infiltrated  with  small 
round  cells.  The  follicles  of  the  gut  are  enlarged  and  elevated  above 
the  surface  of  the  mucous  membrane.  The  Peyer's  patches  are  en- 
larged and  surrounded  by  a  zone  of  hypersemia.     The  villi  show 


528  DISEASES   OF    THE   STOMACH  AND   INTESTINES. 

desquamated  epithelium  and  infiltration  of  the  walls  with  small  round 
cells.  The  follicles  are  swollen,  and  at  the  surface  may  burst  and 
present  follicular  ulcers.  The  epithelium  of  the  gut  may  be  lacking 
in  places. 

Symptoms. — In  the  beginning  there  are  fever  and  slight  vomiting. 
The  movements  are  fluid,  greenish,  and  have  a  disagreeable  odor, 
contain  mucus,  and  are  streaked  with  blood.  They  may  number  ten 
or  twelve  in  twenty-four  hours.  Straining  at  times  accompanies  the 
movement.  As  a  rule  the  infant  is  pale  and  prostrated.  The  char- 
acter of  the  movements  is  unchanged  for  days  or  weeks,  when  improve- 
ment begins  and  recovery  ensues.  On  the  other  hand,  in  protracted 
cases  the  infant  may  develop  a  bronchopneumonia  in  one  or  both 
lungs,  but  may  even  then  recover  under  good  management.  The  pic- 
ture thus  resembles  that  of  a  mild  dysentery,  but  the  subjects  are 
younger,  and  there  is  in  a  number  of  cases  a  history  of  antecedent 
intestinal  disturbance  of  extensive  duration. 

Treatment. — The  treatment  should  be  carried  out  on  the  fame  lines 
as  in  acute  gastro-enteric  infection.  Caution  should  be  exercised  in 
returning  to  a  diet  composed  exclusively  of  milk.  While  in  true  dysen- 
tery in  older  children  I  advise  the  administration  of  milk  sterilized 
in  some  form,  in  younger  infants  such  a  procedure  would  be  unwise. 
I  keep  these  infants  on  a  diet  devoid  of  milk,  such  as  beef -juice  and 
barley-water,  albumin-water  or  solution  of  acorn-cocoa,  as  long  as 
possible.  As  the  character  of  the  movements  improves  the  infants 
are  put  on  a  dilution  of  albumin-water  and  milk  or  cocoa  and  milk, 
or,  what  is  far  preferable,  dextrinized  gruel  and  milk.  The  amount 
of  milk  in  the  dextrinized  mixture  is  gradually  increased  until  the 
quantities  appropriate  to  the  age  of  the  infant  are  given. 

Dysentery  and  Paradysentery  (Ileocolitis ;  Colitis  Contagiosa; 
Coli  Colitis;  Enteritis  Follicularis;  Enterocolitis). — Dysentery  is  an 
acute  infectious  diarrhoeal  affection  of  the  intestine.  In  the  United 
States  it  occurs  both  sporadically  and  in  localized  epidemics.  It  is 
endemic  in  the  tropics,  where  the  etiology  is  somewhat  different  from 
that  in  our  climate.  The  amoebic  infection  seems,  according  to  Kar- 
tullis,  to  be  characteristic  of  the  tropical  form.  Although  amoebic 
dysentery  is  occasionally  seen  here  sporadically  and  in  cases  of  per- 
sons recently  returned  from  the  tropics,  it  is  not  the  form  which  com- 
monly occurs  in  infants  and  children.  The  form  to  which  these 
patients  are  liable  is  seen  during  July,  August,  and  September,  and 
late  in  the  autumn.  It  may  affect  nurslings  who  are  fed  artificially, 
but  most  often  occurs  in  children  who  are  on  a  mixed  diet.  Escherich 
has  described  epidemics  of  limited  character  in  private  families  and 
hospitals.  I  have  met  this  form  of  dysentery  in  sporadic  cases  or 
small  local  outbreaks,  and  have  also  seen  outbreaks  at  seaside  resorts 


DISEASES   OF   THE   STOMACH  AND   INTESTINES.  529 

among  children  of  from  two  to  four  years  of  age  who  had  partaken- 
of  drinking-water  which  had  been  rendered  unfit  for  use  by  con- 
tamination. 

Forms. — There  are  three  forms  of  the  disease:  (1)  the  true  epi- 
demic dysentery  which  occurs  occasionally  in  America  and  on  the 
Continent  but  is  epidemic  and  endemic  in  the  tropics;  (2)  the 
amoebic  form,  which  is  also  endemic  in  the  tropics;  and  (3)  the  form 
which  occurs  in  infants  and  children  in  the  summer  months  as  a  rule 
sporadically,  rarely  epidemically,  except  in  institutions. 

Etiology. — The  essential  cause  of  dysentery  or  ileocolitis  is  now 
recognized  to  be  bacterial. 

Shiga,  in  1897  and  1898,  isolated  a  bacillus  from  the  fseces  of  a 
number  of  cases  of  dysentery  occurring  in  Japan.  H'e  discovered 
also  that  the  blood-serum  of  the  persons  afflicted  caused  a  clumping 
of  the  bacillus  isolated  when  mixed  with  cultures  of  the  latter  in  the 
proper  dilutions.  These  cases  of  dysentery  cited  by  Shiga  did  not 
include  the  amoebic  variety.  The  characteristics  of  the  bacillus  iso- 
lated from  these  cases  closely  resembled  those  of  the  bacillus  of 
typhoid  fever,  except  that  it  was  not  motile. 

In  1902  Flexner  and  his  pupils,  Duval  and  Bassett,  studied  53 
cases  of  diarrhoea  of  the  dysenteric  type,  and  obtained  cultures  of  the 
bacillus  of  Shiga  in  42  of  the  cases  investigated.  Since  then  a  num- 
ber of  investigators  have  studied  the  dysenteries  of  children  in  local 
epidemics,  and  have  substantiated  the  work  of  Duval  and  Bassett. 

In  1903,  Flexner  and  Holt  in  a  collective  study  of  the  occurrence 
of  the  true  Shiga-Kruse  bacillus  and  the  Flexner  bacillus  in  dysen- 
tery or  ileocolitis  of  children  found  that  the  cases  divided  themselves 
into  those  in  which  the  bacillus  of  Shiga-Kruse  was  found  and  those 
in  which  the  Flexner  bacillus  was  present.  The  cases  of  the  latter 
class  were  the  most  frequent.  It  may  be  said  that  the  form  of  ileo- 
colitis met  with  in  the  summer  in  infants  and  children  is  of  the  group 
caused  by  the  Bacillus  dysenteric  of  Flexner  and  allied  bacilli, 
whereas  the  cases  caused  by  the  true  dysentery  bacillus  of  Shiga  and 
Kruse  are  very  uncommon.  The  Flexner  bacillus  differs  from  that 
of  Shiga-Kruse  in  that  it  forms  acid  in  media  and  does  not  ferment 
milk  or  sugar.  Like  the  Shiga-Kruse  bacillus  it  is  immobile  and 
unlike  it  has  little  tendency  to  form  toxins. 

These  facts  have  been  confirmed  by  Jehle,  Leiner  and  Knoepfel- 
macher.  It  has  therefore  been  proposed  to  reserve  the  term  dysen- 
tery for  the  true  epidemic  tropical  form  of  the  disease  and  that  of 
paradysentery  for  the  endemic  form  of  dysentery  which  occurs  in 
infants  and  children  and  which  is  due  to  the  bacillus  dysenteries  of 
Flexner  and  allied  micro-organisms.  The  bacillus  dysenterige  Flex- 
ner has  been  found  in  the  stools  of  normal  children  who  have  been  in 
34 


530  DISEASES    OF   THE   STOMACH  AXD   IXTESTIXES. 

the  Ticinitj  of  children  suffering  from  dysentery  or  who  in  the  past 
may  have  had  an  attack  of  the  disease.  WoUstein,  however,  failed  to 
find  it  in  a  number  of  normal  children.  The  coli  bacilli  (Escherich ) 
and  streptococci  found  in  the  intestine  in  dysentery  or  paradysentery 
play  an  important  role  in  the  mixed  infections  of  these  diseases. 

Morbid  Anatomy. — Dysentery  may  affect  different  sections  of  the 
intestine  at  the  same  time,  the  rectal  or  sigmoid  flexure  alone,  the 
ascending  colon,  the  transverse  or  the  descending  colon  only.  In  rare 
cases  the  disease  may  pass  beyond  the  ileocsecal  valve  and  involve  the 
lower  part  of  the  ileum.  There  are  two  forms  which  may  be  present 
separately  or  simultaneously,  the  catarrhal  and  the  necrotic  form. 

In  the  milder  catarrhal  form  of  dysentery  the  mucous  membrane 
is  hypersemic  and  swollen,  and  the  summits  of  the  intestinal  folds  are 
studded  with  hemorrhages  in  small  foci  or  streaks.  The  submucosa 
is  infiltrated  with  small  round  cells  and  the  vessels  filled  with  blood. 
The  epithelium  of  the  follicles  is  swollen  and  proliferated,  and  there 
is  infiltration  of  the  surrounding  connective  tissue  with  round  cells. 
In  severe  forms  the  surface  of  the  mucous  membrane  is  covered  with 
mucus  containing  leucocytes  and  blood-cells.  The  follicles  are  ele- 
vated above  the  surface.  In  other  cases  the  intestine  is  studded  with 
ulcerations  which  mark  the  necrotic  follicles.  The  ulcerations  reach 
to  the  muscularis  mucosa.  If  the  process  extends  to  the  small  intes- 
tine the  Peyer's  patches  are  swollen  and  surrounded  by  a  hypersemic 
zone. 

If  the  disease  has  advanced  to  the  necrotic  stage,  the  mucosa  is 
thickened  and  infiltrated  with  round  cells.  There  are  areas  of  loss 
of  tissue  which  extend  deep  to  the  muscular  coat  (gangrene).  The 
mucous  membrane  is  covered  with  a  grayish  exudate  of  a  pseudo- 
membranous character.  In  severe  cases  large  areas  of  the  mucous 
membrane  may  necrose  and  be  cast  off.  The  necrotic  areas  show 
an  abundant  invasion  of  bacteria  of  the  streptococcus  and  coli  type, 
in  scattered  masses  or  zoogloea.  The  lymph-nodes  of  the  mesentery 
are  swollen;  the  spleen  may  be  enlarged;  the  kidneys  may  show  degen- 
erative changes,  and  the  lungs  may  be  the  seat  of  bronchopneumonia. 

Symptoms. — The  symptoms  of  dysentery  in  infants  and  children 
closely  resemble  those  seen  in  the  adult  subject.  The  onset  may 
follow  some  indiscretion  of  diet  or  be  entirely  independent  of  any 
such  error.  There  may  be  a  preceding  headache,  and  there  is,  as  a 
rule,  some  fever.  Abdominal  pain  is  the  first  symptom  until  diarrhoea 
sets  in.  The  diarrhoea  at  first  resembles  an  ordinary  dyspeptic  diar- 
rhoea, but  in  a  few  hours  or  after  one  or  two  movements,  it  assumes 
the  characteristics  which  mark  it  as  specific.  The  patient  passes 
stools  which  are  fluid  and  contain  mucus  mixed  with  blood  and  shreds 
of  tissue,  and  which  may  have  an  offensive  odor.     They  are  passed 


DISEASES    OF    THE   STOMACH  AND    INTESTINES. 


531 


with  miicli  abdominal  pain  and  rectal  tenesmus.  If  the  abdominal 
pain  is  severe  there  are  vomiting  and  great  prostration.  As  many 
as  twenty  to  thirty  small  bloody  mucoid  movements  may  be  passed 
daily. 


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Dysentery  of  ordinary  severity.     First  week  of  illness.     Duration  three  weeks  ;  recovery. 

Boy,  seven  years  of  age. 

The  fever  varies  in  intensity.  In  mild  cases  the  temperature  may 
range  from  101°  to  102°  F.  (38°  to  38.5°  C.)  (Fig.  109)  ;  in  severe 
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Necrotic  colitis ;  fatal,  in  a  girl  sis  years  of  age. 

sists  beyond  a  few  days,  there  is  rapid  emaciation  and  the  abdomen 
becomes  sunken  and  board-like.     In  some  cases  palpation  in  the  region 


532  DISEASES    OF    THE   STOMACH  AND   INTESTINES. 

of  the  cEeciim  and  ascending  colon  may  detect  the  contracted,  thick- 
ened gut.  In  severe  forms  of  the  necrotic  type  it  is  possible  to  mark 
out  the  cEecum  and  ascending  colon  as  a  contracted,  thickened  tube. 
In  protracted  cases  the  spleen  becomes  enlarged  and  the  tongue  dry 
and  coated,  in  this  respect  resembling  the  condition  seen  in  typhoid 
fever.  Multiple  hemorrhages  may  appear  under  the  skin.  The  urine 
contains  albumin,  and  in  some  cases  hyaline  and  epithelial  casts. 

Course. — The  fulminating  cases  run  their  course  in  a  few  days 
with  high  fever,  terminating  in  death.  Other  cases  may  be  compara- 
tively mild  and  last  only  a  few  days  or  a  week.  In  such  cases  there 
may  be  recurrences.  In  other  cases  the  disease  runs  a  course  of  from 
three  to  six  weeks.  After  this  period,  from  time  to  time,  blood,  evi- 
dently derived  from  bleeding  ulcers  in  process  of  repair,  may  appear 
in  the  movements.  The  movements  gradually  become  formed  and 
fsecal  in  character,  and  the  patient  recovers.  In  cases  which  have 
come  under  my  care  in  hospital  service,  the  disease  ran  a  moderately 
severe  course  until  the  seventh  or  eighth  day.  The  fever,  however, 
remained  high  and  delirium  set  in  on  the  ninth  day.  The  appear- 
ance of  the  patient  became  septic,  sopor  supervened,  and  the  urine 
and  faeces  were  passed  involuntarily.  Death  took  place  on  the  thir- 
teenth day.  In  other  cases  of  a  severe  necrotic  type  death  took  place 
at  the  end  of  a  week. 

Complications. — The  most  dangerous  complication  is  perforation 
and  general  peritonitis.  Periproctitic  abscess  may  occur,  Avith  sub- 
sequent fistula.  In  septic  cases,  abscess  of  the  liver  and  spleen  have 
been  observed.  Hemorrhages  may  occur  under  the  skin  late  in  the 
disease.  In  all  of  my  cases  these  were  quite  extensive,  but  recovery 
nevertheless  took  place.  In  one  fatal  case  I  noted  metastatic  paro- 
titis. Some  authors  have  recorded  arthritis  as  a  complication;  as  a 
rule  it  retrogrades  and  recovery  takes  place. 

Prognosis. — The  prognosis  varies  with  the  severity  of  the  case. 
The  mortality  ranges  from  30  to  40  per  cent.  The  croupous  or 
necrotic  cases  are  very  fatal.  With  good  management  the  mild  cases 
give  a  favorable  prognosis.  The  severity  of  the  infection  and  the 
prevalence  of  an  epidemic  will  influence  the  course  of  the  affection. 

Treatment. — Prophylaxis.- — The  movements  are  not  only  infec- 
tious, but  may  also  communicate  the  disease  to  others  if  a  particle 
is  introduced  into  the  gut.  The  hands  of  the  patient  and  his  body 
should  be  kept  scrupulously  clean  to  avoid  reinfection.  The  move- 
ments should  be  disinfected  in  the  same  manner  as  those  of  a  patient 
suffering  with  typhoid  fever.  The  hands  of  the  nurse  should  be 
scrupulously  cleansed  and  washed  in  an  antiseptic  solution. 

General. — The  patient  is  given  a  cathartic,  preferably  castor  oil, 
as  the  initial  step  of  treatment.     In  this  way  all  irritating  food  par- 


DISEASES    OF    THE   STOMACH  AND   INTESTINES.  533 

tides  and  residual  faeces  are  cleared  from  the  gut.  All  food,  even 
milk,  is  withheld  at  first.  The  patient  for  the  first  twenty-four  hours 
is  given  a  solution  of  egg-albumin,  acorn-cocoa,  beef-juice  broths,  or 
expressed  beef -juice  and  barley-water  in  equal  parts.  The  following 
are  the  lines  along  which  the  later  management  of  these  cases  should 
proceed : 

a.  An  absolutely  non-irritating  and  easily  assimilable  food  is  given. 

h.  The  pain  and  tenderness  are  relieved  with  drugs,  the  diarrhoea 
being  also  partially  controlled  in  this  manner. 

c.  The  rectum  is  irrigated. 

After  a  day  or  two,  during  which  the  patient  has  been  fed  upon 
albumin-water,  expressed  beef-juice,  and  barley-water  or  acorn-cocoa 
solutions,  sterilized  or  pasteurized  milk  is  substituted.  In  these 
cases,  as  in  typhoid  fever,  the  patients  are  given  during  twenty-four 
hours,  two  or  more  quarts  of  milk  sterilized  at  212°  F.  (100°  C.) 
or  pasteurized  at  164°  F.  (73°  C).  I  wait  until  the  severely  acute 
symptoms  have  subsided  before  placing  these  patients  on  a  milk  diet. 
At  best,  milk  leaves  a  large  residue  in  the  gut,  and  in  the  acute  stage 
of  the  disease  the  coagulum  may  in  a  mechanical  way  irritate  the 
acutely  inflamed  walls.  Pasteurized  and  sterilized  milk  is  well  borne 
in  the  later  stages  of  the  affection.  Milk  in  a  raw  state,  no  matter 
how  good,  will  sometimes  tend  to  aggravate  the  acute  symptoms. 
Pain  and  tenesmus  are  relieved  by  the  exhibition  of  Dover's  powder, 
grains  -J  to  ij  (0.03  to  0.12),  every  two  hours  according  to  the  age 
of  the  infant  or  child.  Codeine  sulphate,  grain  i  to  i  (0.01  to  0.015), 
according  to  the  age  of  the  patient,  is  preferable  to  morphine  or  tinc- 
ture of  opium.  The  administration  of  powdered  ipecacuanha  will  be 
found  very  useful  in  certain  cases.  In  others  the  vomiting  rather 
interferes  with  its  administration;  grains  j  to  ij  or  iij  (0.06  to  0.12 
or  0.2)  every  two  or  three  hours  are  indicated.  It  may  be  combined 
with  bismuth  subcarbonate,  grain  v  (0.3)  every  three  hours. 

In  older  children  this  mode  of  treatment  has  lately  given  good 
results.  I  have  had  no  experience  with  the  administration  of  lead 
salts.  In  the  acute  cases  the  internal  administration  of  preparations, 
such  as  tannigen,  is  irritating. 

Enemata.- — Rectal  enemata  should  be  employed  with  care  in  the 
treatment  of  colitis  or  dysentery.  Unless  caution  is  exercised,  their 
use  is  in  many  cases  followed  by  an  exacerbation  or  perpetuation  of 
symptoms.  The  most  useful  form  of  enema  is  the  warm  (108°— 110° 
F.,  42.2°-43.3°  C.)  saline  (Cantani)  solution.  Fully  a  quart  of 
fluid  is  allowed  to  flow  into  the  gut.  The  greater  part  of  it  returns, 
but  I  believe  that  if  a  portion  of  this  solution  is  retained  it  acts  in 
the  manner  of  enteroclysis  and  supports  the  patient.  These  enemata 
are  given  three  times  in  the  twenty-four  hours,  for  a  day  or  two ;  they 


534  DISEASES   OF    THE   STOMACH  AND   INTESTINES. 

are  subsequently  given  twice  a  day,  and  finally,  as  the  symptoms  sub- 
side, only  once  a  day.  I  have  never  been  able  to  convince  myself 
that  silver  nitrate  (1:1000)  or  tannic  acid  added  to  the  enemata  is 
of  value.  On  the  contrary,  I  believe  that  in  cases  in  the  acute  stage 
these  medicated  enemata  are  distinctly  irritating.  In  the  later  stages 
of  the  disease,  small  quantities  of  fluid  blood  are  passed  with  the 
fsecal  movements,  tenesmus  being  present ;  small  enemata  of  silver 
nitrate  (1:1000)  given  low  down  twice  daily  cause  cessation  of  the 
bleeding  which  is  due  to  the  presence  of  ulcers  low  down  in  the 
rectum.  In  the  subacute  stage,  the  enemata  will  often  be  followed  by 
an  exacerbation  of  bloody  mucous  passages.  Under  these  conditions 
it  is  well  to  discontinue  the  enemata  and  to  watch  the  results  of  the 
suspension  of  local  treatment. 

Serum. — The  serum  devised  by  Flexner,  though  protective  in 
animals  against  infection,  is  not  effective  in  the  human  subject. 

Amoebic  Dysentery  (Amoebic  Colitis). — Amoebic  dysentery  is  not, 
strictly  speaking,  a  disease  of  infancy  and  childhood.  It  is  caused 
by  the  Amoebse  coli  of  Losch.  Of  35  cases  reported  by  Harris,  4 
were  under  ten  years  of  age.  Amberg  has  recently  published  5  addi- 
tional cases.  I  have  seen  two  cases  in  my  hospital  service,  one  in  a 
boy  8  years  of  age,  another  in  a  girl  11  years  old.  The  etiological 
factor  is  the  Amoebse  coli,  which  are  found  in  large  numbers  in  the 
movements.  With  the  amoeba,  Charcot-Leyden  crystals  are  found  in 
most  cases.  The  cases  published  by  Amberg  were  of  a  mild  type, 
and  seemed  in  no  way  to  differ  in  symptomatology  from  the  form  of 
the  disease  seen  in  the  adult  subject.  There  were  diarrhoea  of  a 
bloody  character,  tenesmus,  and  in  some  cases  fever  and  prostration. 
As  many  as  from  four  to  six  movements  containing  blood  and  mucus, 
and  microscopically  eosinophile  cells,  were  passed  in  twenty-four 
hours. 

After  the  acute  symptoms  subside  there  may  be  recurrences  in  the 
form  of  attacks  of  diarrhoea  with  blood  and  mucus  in  the  evacuations 
and  the  appearance  from  time  to  time  of  the  amoebse  in  the  stools. 

Diagnosis. — The  diagnosis  is  made  from  the  presence  of  the 
amoebse  in  the  movements.  Bloody  passages  containing  Charcot- 
Leyden  crystals  should  cause  the  physician  to  entertain  a  suspicion 
of  the  presence  of  this  affection. 

Other  amoebse,  such  as  the  Monocercomonas  hominis  (Grassi), 
have  been  found  in  the  movementsof  infants  suffering  from  diarrhoea. 
Epstein  describes  an  epidemic  of  diarrhoea  in  which  the  monocer- 
comonas abounded  in  the  movements.  He  thinks  that  in  this  epi- 
demic the  diarrhoea  was  caused  by  well-water  which  contained  the 
amoebse.  I  have  found  the  Monocercomonas  hominis  in  the  move- 
ments of  infants  who  were  suffering  from  diarrha^a,  but  also  of  those 


DISEASES    OF   THE   STOMACH  AND    INTESTINES.  535 

whose  bowels  were  not  in  an  abnormal  condition.  Tbe  role  of  the 
monocercomonas  as  an  etiological  factor  in  the  causation  of  these 
diarrhoeas  is  not  understood.  It  is  doubtful  whether  they  have  any 
causal  connection  with  the  diarrhoea. 

Treatment. — The  treatment  consists  in  dieting  on  a  fluid  diet,  the 
administration  of  quinine  internally,  and  injections  in  the  rectum  of 
solutions  of  quinine  1  in  500. 

Constipation  in  Infants  and  Children. — Constipation  may  be 
classified  as  congenital  and  acquired. 

Congenital  Constipation. — Congenital  constipation  is  noticed  imme- 
diately after  birth,  or  in  the  days  subsequent  to  it.  The  causes  of 
congenital  constipation  are  generally  an  absence  of  the  anus  or  its 
occlusion  by  a  thin  membrane,  or  by  a  thick,  hard  membrane  resem- 
bling the  skin ;  or  there  may  be  an  anus  and  a  shallow  or  deep  cul-de- 
sac  leading  from  the  anus  for  some  distance  into  the  rectum,  or  this 
may  be  occluded  at  a  varying  distance  from  the  external  orifice.  The 
rectum  may  be  occluded  by  one  or  several  membranes.  Its  walls  may 
be  thickened,  so  that  meconium  or  fseces  cannot  pass ;  or  its  walls  may 
be  agglutinated.  The  rectum,  as  has  been  stated,  may  end  at  some 
distance  from  the  anus  in  a  blind  cul-de-sdc,  and  from  this  point 
upward  the  rectum  may  either  exist  in  its  normal  calibre,  or  may  be 
simply  indicated  by  a  fibrous  cord;  in  other  words,  there  may  be  a 
congenital  absence  of  the  rectum.  The  rectum  may  end  in  a  preter- 
natural opening  into  the  bladder,  the  urethra  or  vagina,  or  may,  by  a 
common  opening,  a  sort  of  cloaca,  terminate  in  the  perineum  through 
the  urethra  or  vagina.  In  such  cases  there  is  scarcely  constipation, 
but  rather  a  difiiculty  in  voiding  the  fseces.  There  may  be,  as  has 
been  intimated,  partial  or  complete  absence  of  the  rectum  or  colon; 
or  a  large  part  of  the  larger  bowel  may  be  absent,  or  it  may  be  stenosed 
in  part  of  its  extent  and  dilated  in  another  part.  It  may  be  abnor- 
mally contracted.  The  colon  or  any  part  of  it  may  be  rudimentary. 
There  may  be  obstruction,  as  in  the  rectum,  in  any  part  of  the  course 
of  the  colon.  There  may  be  a  congenital  occlusion  of  the  ileocsecal 
valve. 

Jacobi  has  described  a  case  of  congenital  constipation  due  to  mis- 
placement of  the  large  gut  and  inordinate  dilatation  of  this  viscus. 
In  some  cases  of  congenital  malformation  the  small  intestine  may  be 
entirely  obliterated;  or  the  small  intestine  in  part  of  its  extent  may 
be  normal,  especially  the  duodenum ;  whereas  the  ileum  may  be  rudi- 
mentary and  the  large  gut  enormously  dilated.  There  are  cases  on 
record  in  which  there  was  no  connection  between  the  large  and  the 
small  intestine,  and  there  may  be  congenital  stricture  in  any  part  of 
the  small  intestine,  either  the  duodenum  or  the  ileum;  or  there  may 


536  DISEASES   OF    THE   STOMACH  AND   INTESTINES. 

be  an  obstruction  due  to  a  small  diaphragm  extending  into  the  lumen 
of  the  intestine  in  any  part  of  its  course. 

It  may  be  seen  from  a  simple  enumeration  of  the  causes  of  con- 
genital constipation  that  the  conditions  found  are  extremely  varied, 
and  in  most  cases  cannot  be  remedied  by  surgical  means  unless  the 
obstruction  diagnosed  is  low  down  in  the  rectum  or  sigmoid  flexure, 
and  exists  without  any  accompanying  deformity  of  the  rest  of  the 
intestine.  A  congenital  absence  or  rudimentary  condition  of  the 
small  or  large  intestine  must  eventually  prove  fatal.  The  symptoms 
of  all  the  cases  recorded  of  congenital  constipation  are  those  of  obstruc- 
tion, in  the  end  resulting  in  rejection  of  all  fluids,  vomiting,  and 
ending  fatally  if  unrelieved.  A  further  discussion  of  this  form  of 
constipation  is  scarcely  within  the  scope  of  this  treatise. 

Acquired  Constipation. — Acide. — Acute  constipation  is  really  a 
surgical  disease,  and  is  caused  in  infants  and  children  by  some  acute 
obstruction  of  the  gut,  such  as  intussusception,  volvulus,  strangula- 
tion, through  a  slit  in  the  omentum,  strangulation  by  peritonitic 
bands,  or  by  the  persistence  of  Meckel's  diverticulum;  hernia  of  all 
kinds,  strangulation  or  paralysis  of  the  intestine  as  a  result  of  trau- 
matism. Peritonitis  may  cause  acute  constipation,  and  with  this  we 
must  consider  diseases  such  as  appendicitis. 

Foreign  bodies  may  obstruct  the  lumen  of  the  bowel.  Watkins 
relates  the  case  of  a  boy,  ten  years  of  age,  who  had  swallowed  an 
immense  quantity  of  figs,  which  obstructed  the  lower  part  of  the  intes- 
tine near  the  anus,  and  had  to  be  removed  by  surgical  means  before 
movements  were  established.  J.  Lewis  Smith  relates  the  case  of  a 
girl,  four  years  old,  in  whom  acute  constipation  developed  suddenly 
as  the  result  of  the  impaction  of  a  mass  of  intertwined  worms  in  the 
intestine.  This  acute  obstruction  was  attended  by  distention  of  the 
abdomen  and  great  suffering.  A  large  gall-stone  is  mentioned  as 
obstructing  the  ileocsecal  valve,  and  in  this  way  suspending  for  a 
time  the  passage  of  faeces  through  this  structure. 

The  diagnosis  of  acute  constipation  presupposes  a  diagnosis  of 
the  primary  causal  condition,  and  this  can  only  be  made  by  a  careful 
study  of  the  case.  Cases  of  intussusception,  volvulus,  strangulation, 
either  by  bands  or  hernia  or  forms  of  peritonitis,  will  give  symptoms 
of  these  diseases.  It  is  scarcely  the  place  here  to  enter  upon  these 
fully.  In  those  cases  in  which  worms  cause  obstruction,  the  diagnosis 
can  only  be  made  after  relief  has  been  established  by  passage  of  the 
corpus  deliciu,  unless  enough  faeces  are  voided  to  examine  the  same 
for  eggs  of  the  worms. 

Chronic. — Chronic  constipation  may  be  dependent  upon  obstruc- 
tion of  the  large  or  small  intestine  in  any  part  of  its  extent,  either 
by  morbid  growths,  sarcomata,  carcinomata,  or  tuberculous  perito- 


DISEASES    OF    THE   STOMACH   AND    INTESTINES.  537 

nitis.  The  latter  form  of  obstruction  by  tuberculous  masses  is  of 
especial  interest,  inasmuch  as  these  cases  form  a  part  of  the  sympto- 
matology of  tuberculous  peritonitis.  I  saw  a  case  of  tuberculous 
peritonitis  in  which  large  masses  were  palpable  in  the  abdomen,  and 
in  which  one  of  these  masses  involved  the  descending  colon  to  such 
an  extent  as  to  almost  completely  occlude  its  lumen. 

Anal  fissure  is  a  common  cause  of  chronic  constipation  in  infants 
and  children.  In  these  cases  there  is  always  a  history  of  great  pain 
when  the  movement  is  passed,  and  for  some  time  afterward.  Blood 
may  accompany  movements  when  there  is  a  fissure  of  the  anus. 
Children  suffering  in  this  manner  do  not  void  a  movement  for  days, 
and  when  the  movement  is  passed  the  suffering  sometimes  is  intense. 
In  some  children  there  is  a  spasm  of  the  anus  due  to  a  nervous  condi- 
tion, and  sometimes  brought  about  by  an  excoriated  state  of  the  anus. 
Examination  does  not  reveal  any  fissure,  but  there  is  a  distinct  spasm 
of  the  sphincter  which  prevents  the  successful  evacuation  of  the 
rectum.  In  all  of  these  cases  chronic  constipation  is  really  a  surgical 
disease,  and  can  only  be  relieved  by  surgical  measures.  In  some 
cases  caused  by  cancerous,  sarcomatous,  or  tuberculous  growths  the 
surgeon  is  unable  to  relieve  the  patient.  Constipation  caused  by  anal 
fissure,  spasms  of  the  sphincter,  or  excoriations  around  the  anus 
yields  more  successfully  to  surgical  treatment,  which  is  the  same  as  a 
treatment  for  similar  conditions  in  the  adult,  viz.,  forcible  dilatation 
of  the  sphincter. 

Chronic  Habitual  Constipation. — The  next  form  of  chronic  con- 
stipation is  that  which  most  interests  the  general  practitioner,  and  is 
known  as  chronic  habitual  constipation.  Of  all  the  conditions  within 
the  domain  of  pediatrics  habitual  constipation  is  the  most  difficult 
of  management.  It  is  not  always  possible  in  these  infants  and  chil- 
dren to  fix  on  the  absolute  causes  of  a  constipated  habit. 

Etiology. — Infants  at  the  breast  may  be  constipated  from  birth, 
though  normal  in  every  other  respect,  and  continue  this  habit  through- 
out childhood.  In  many  of  these  cases  the  mother  is  of  a  constipated 
habit.  Some  signs  of  rachitis  may  be  present  in  certain  cases.  In 
these  cases,  however,  it  is  reasonable  to  conclude  that  the  mother's 
milk  is  lacking  in  some  element,  such  as  fat,  which  tends  to  perpet- 
uate the  constipation.  In  other  cases  the  milk  may  be  absolutely 
normal,  and  still  a  condition  of  atony  of  the  gut  of  an  hereditary  type 
may  exist. 

Constitutional  Dyscrasia. — Rachitis,  when  marked,  is  associated 
with  constipation  in  a  large  proportion  of  cases.  In  a  manner  similar 
to  the  bones,  so  the  muscular  apparatus  lacks  tone,  and  it  is  not  sur- 
prising that  with  the  muscular  atony  the  glandular  elements  of  the 
gut  should  be  deficient  in  furnishing  elements  necessary  to  a  normal 


538  DISEASES   OF   THE   STOMACH  AND   INTESTINES. 

maintenance  of  the  functions  and  evacuation  of  the  intestinal  contents. 

Heredity. — Heredity  has  been  named  as  a  cause  of  constipation 
in  breast-fed  infants,  and  it  is  not  infrequent  to  meet  the  same  condi- 
tion, possibly  due  to  the  same  cause,  in  bottle-fed  infants. 

Incorrect  Feeding. — Incorrect  feeding  is  certainly  one  of  the  most 
frequent  causes  of  constipation  in  artificially  fed  infants  and  children. 
Some  infants  who  have  been  started  on  very  dilute  modifications  of 
milk  are  constipated  from  the  beginning,  or  their  constipation  has 
been  fostered  by  heating  the  milk  to  a  greater  or  less  degree,  and  in 
these  cases  the  constipation,  if  allowed  to  persist  for  any  length  of 
time,  is  perpetuated  into  the  period  of  childhood. 

In  other  cases  raw  milk  will  cause  constipation.  In  older  chil- 
dren a  simple  diet  of  two  or  three  articles  of  food,  which  have  been 
religiously  adhered  to  from  the  time  of  weaning  to  a  varying  period 
of  childhood,  is  the  direct  cause  of  constipation.  There  has  been  a 
failure  in  these  cases  to  give  an  appropriately  mixed  diet.  I  have 
seen  constipated  children,  at  varying  periods  of  childhood,  who  have 
been  kept  systematically  on  a  diet  of  milk  and  fruits,  for  fear  that 
any  other  article  of  diet  would  cause  intestinal  disturbance.  The 
result  has  been  an  inordinate  constipation  of  chronic  duration  with 
accompanying  symptoms. 

Symptoms. — One  can  scarcely  speak  of  the  symptoms  of  constipa- 
tion which  in  itself  is  a  symptom  of  disturbed  intestinal  conditions 
and  metabolism.  There  are  certain  features,  however,  of  the  move- 
ments of  constipated  infants  and  children  which  are  of  importance. 

Stools. — The  intestinal  movements  of  infants  suffering  from  con- 
stipation may  be  hard  and  formed,  or  may  be  unformed  and  dry. 
Ordinarily  a  healthy  infant  has  two,  three,  or  four  movements  daily, 
the  rule  being  two.  A  healthy  infant  may  have  six  movements  a 
day  and  still  be  within  the  limits  of  health.  We  judge  by  the  char- 
acter rather  than  by  the  number  of  the  movements.  The  normal 
characteristics  of  intestinal  evacuations  have  been  dilated  upon  else- 
where, and  the  reader  is  referred  to  the  section  treating  of  this  subject. 

In  constipated  infants  the  movements  consist  almost  entirely  of 
marble-like  masses,  resembling  those  seen  in  the  lower  animals.  They 
rarely  have  a  movement  unaided.  They  have  great  pain  in  passing 
the  faeces,  and  in  time  develop  fissuration  of  the  anus  to  a  greater  or 
less  extent,  with  accompanying  bleeding  due  to  the  stretching  of  the 
fissure.  In  other  cases  this  bleeding  is  accompanied  by  slight  pro- 
lapsus of  the  gut  during  the  movement,  which  often  creates  the  im- 
pression that  the  infant  is  suffering  from  hemorrhoids.  •  Many  of 
these  constipated  movements  are  coated  with  mucus,  or  mucus  is 
voided  after  the  movement  is  passed.  These  masses  are  not  mem- 
branous, and  if  examined  will  be  seen  to  be  composed  mostly  of  mucus. 


DISEASES   OF   TEE   STOMACH  AND   INTESTINES.  539 

Other  Symptoms.- — Constipated  infants  after  a  time  develop  a 
pallor  and  anaemia  which  is  characteristic,  and  seem  to  suffer  from 
intestinal  absorption  and  toxaemia  which  results  from  time  to  time  in 
periodical  attacks  of  vomiting,  discussed  elsewhere.  These  children 
also  complain  from  time  to  time  of  a  vertigo  and  nausea,  especially 
in  the  morning.  Many  children  who  are  thus  constipated  will  reject 
their  food  in  the  morning.  They  lose  their  appetite  and  have  all  the 
symptoms  of  intestinal  intoxication. 

Treatment. — The  treatment  of  constipation  is  dietetic  and  medic- 
inal. If  the  infants  who  are  constipated  are  fed  at  the  mother's  or 
nurse's  breast,  the  bowels  of  the  mother  or  nurse  need  regulating,  and 
they  should  take  regular  exercise.  In  many  cases  a  nutritious  diet 
to  the  mother  or  nurse  will  cause  the  milk  to  change  in  its  composi- 
tion, containing  more  fat,  and  thus  improve  the  condition  in  the 
infant.  On  the  other  hand,  an  increase  of  the  fats  will  decidedly 
aggravate  the  constipation  in  some  children.  Therefore  we  diminish 
the  fat  of  the  milk  in  such  cases.  If  artificially  fed  children  are 
constipated,  the  heating  of  the  milk  should  be  stopped.  If  for  some 
reason  milk  must  be  pasteurized  or  sterilized,  the  time  of  heating 
should  be  reduced  to  a  minimum.  Constipated  infants  may  be  fed 
on  raw  milk  if  the  milk  is  fresh  and  carefully  kept.  The  formula 
should  contain  sufficient  fat  to  make  the  diet  nutritious,  but  the  fat 
should  not  form  more  than  4  per  cent,  of  the  mixture.  As  a  rule, 
artificially  fed  infants  do  well  on  a  smaller  quantity  of  fat  than  the 
average  breast-fed  infant.  Thus  2.5  to  3  per  cent,  of  fat  meet  the 
requirements  of  most  infants.  Some  infants  fed  on  raw  milk  and 
an  increase  of  fats  become  more  constipated.  The  stools  are  hard 
and  dry  and  there  is  an  unmistakable  anaemia. 

Children  from  the  sixteenth  month  to  the  second  year  who  suffer 
from  constipation  should  be  gradually  weaned  to  a  mixed  diet.  In 
many  cases  this  procedure  will  regulate  the  bowels.  The  children 
should  be  given  green  vegetables,  such  as  peas  and  spinach,  in  the 
form  of  a  puree.  The  diet  should  include  cereals  of  the  various 
varieties,  especially  wheatena,  oatmeal,  granum,  and  rusk  (Zwieback). 
The  milk  should  be  given  raw  with  a  moderate  mixture  of  cream. 
Fruit,  such  as  oranges,  raw  apples,  and  pears,  is  also  given  in  moder- 
ation. If  the  constipation  cannot  be  remedied  by  these  measures, 
recourse  is  had  to  medicinal  treatment. 

Cathartics. — At  best,  cathartics  are  a  makeshift.  Some  older 
children  will  do  well  with  a  small  dose,  grain  Yioo  (0.0004),  of 
strychnine  once  a  day,  and  a  simple  cathartic,  such  as  the  aromatic 
fluid  extract  of  cascara,  twice  or  three  times  a  week.  A  child  two 
years  of  age  may  be  given  TIX  xx  to  xxx  (1.0  to  2.0)  once  a  day.  The 
preparations  of  rhubarb  are  useful,  but  do  not  give  uniformly  satis- 


540    .  DISEASES   OF    TEE    STOMACH  AND   INTESTINES. 

factory  results.  The  mercurial  cathartics  are  available  only  once  a 
week  in  the  majority  of  cases.  We  are  thus  reduced  to  the  necessity 
of  giving  suppositories  or  enemata.  With  very  young  infants  a  small 
cylindrical  piece  of  soap  inserted  with  oil  into  the  rectum  once  a  day 
will  be  effective.  With  older  children  the  glycerin  suppository  given 
every  other  day  is  very  useful. 

Enemaia. — In  many  cases  it  is  necessary  to  give  enemata :  to 
younger  infants  they  are  given  once  a  day;  to  older  children  an 
enema  is  given  twice  a  week.  When  the  child  becomes  pale  and 
listless  a  brisk  cathartic  aided  by  a  large  high  enema  is  given.  In 
this  way  an  attack  of  vomiting  may  be  avoided. 

Massage. — Massage  of  the  abdomen  gives  very  unsatisfactory 
results.  Gymnastics  or  calisthenic  exercises  in  the  morning  after  a 
bath  are  useful  in  some  cases. 

Hahits. — The  inculcating  of  a  habit  of  evacuating  the  bowel  at 
regular  intervals  daily  will  do  much  toward  overcoming  constipation. 
The  children  are  placed  on  the  toilet  and  are  taught  to  keep  their 
minds  on  the  object  to  be  attained.  The  results  in  some  cases  are 
gratifying. 

Useful  f ormulse  are  the  following : 

1.  Pulv.  glycyrrMzae  comp.    .     .     .  3ss  to  5j  (2.0  to  4.0)  as  necessary. 

2.  Infus.  sennse  comp 3j-3ij  (4.0-8.0)  as  necessary.     , 

3.  PodophyUin gr.  ij  (0.12). 

Syr.  rhei  arom Jij  (60.0). 

Sig.         3j  (4.0)  pro  dosi. 

Congenital  Dilatation  of  the  Colon,  With  or  Without  Hyper- 
trophy of  Its  Walls  (Hirschsprung's  Disease). — This  deformity  is 
one  of  the  rarer  causes  of  habitual  constipation  in  infants  and  chil- 
dren.    We  distingaiish  three  forms  of  this  condition. 

a.  In  this  form  there  is  an  increase  in  the  length  of  the  colon 
descendens  and  the  sigmoid  flexure.  As  a  result  of  the  increased 
length  of  the  colon  this  portion  of  the  intestine  bends  two  or  three 
times  on  itself.  There  is  a  stagnation  of  the  fseces  and  consequent 
constipation.  Toxaemia  results  and  emaciation  follows.  With  the 
above  there  are  symptoms  of  fermentation  in  the  gut,  and  constipation 
alternates  with  diarrhoea.  The  diarrhoeal  movements  are  foul,  con- 
taining mucus  and  blood.     There  is  some  meteorism. 

Prognosis. — The  prognosis  of  this  form  is  not  bad,  provided  a 
complicating  colitis  does  not  ensue.  As  the  child  grows  older  the 
above  symptoms  improve  and  normal  conditions  ultimately  supervene. 

h.  In  this  class  of  cases  the  colon  is  not  only  lengthened  and 
dilated,  but  its  walls  are  thickened.  Such  are  the  cases  of  Mya, 
Formad,  Griffith,  and  Hirschsprung.  According  to  Concetti,  the 
mucosa  is  not  only  thickened,  but  the  connective  tissue  and  muscular 


DISEASES    OF    THE   STOMACH   AND    INTESTINES.  541 

coats  of  the  intestine  show  the  same  changes,  and  the  arteries  are  the 
seat  of  arteritis.  The  cases  belonging  to  this  class  in  the  literature 
range  from  eight  to  fifty  years  of  age.  It  is  in  this  set  of  cases  that 
stagnation  of  the  faeces  is  accompanied  at  times  with  ulceration  of 
the  gut. 

c.  In  this  class  of  cases  there  is  a  combination  of  the  dilatation  of 
the  colon  with  thin  walls;  or  the  colon  may  be  normal  in  its  lower 
portion  and  slightly  ectatic,  with  hypertrophied  walls  above. 

Symptoms. — The  symptoms  of  the  last  two  sets  of  cases  are  more 
severe  in  the  younger  and  milder  in  the  older  children.  They  are 
severe  if  the  condition  has  lasted  for  two  or  three  years,  and  milder  if 
the  patient  has  survived  until  the  tenth  or  twelfth  year.  From  the 
second  to  the  fourth  day  after  birth  great  meteorism  appears.  ISTo 
meconium  is  passed  for  some  time,  and  there  is  no  stenosis  of  the 

Fig.  111. 


Infant  nine  weeks  old.  Congenital  dilatation  of  the  colon,  strictures  in  the  sig- 
moid flexure.  Enormous,  abdominal  distention  ;  inordinate  constipation ;  coils  of  large 
intestine  visible  on  the  abdomen.     Eventual  death. 

gut;  laxatives  succeed  in  bringing  away  only  a  small  amount  of 
meconium  or  fseces.  The  constipation  is  very  obstinate,  the  faeces 
are  foul-smelling,  and  from  time  to  time  colitis  may  supervene,  or 
every  eight  to  thirty  days  hard,  malodorous  masses  are  evacuated  with 
slime  and  blood.  There  is  a  condition  of  an  auto-intoxication  and 
a  resultant  cachexia.  The  abdomen  becomes  enormously  distended, 
and  the  coils  of  the  intestine  can  be  made  out  on  the  surf  ace  (Fig.  111). 
The  children  die  during  the  first  and  second  years  of  life,  either 
through  cachexia  or  perforation  of  the  gut.  Of  the  21  cases  collected 
by  Concetti  only  2  lived.  One  was  a  case  of  his  own,  and  another 
that  of  Osier;  in  both  an  artificial  anus  was  made  for  the  relief  of 
the  condition.     Colitis,  with  or  without  perforation  of  the  intestine, 


542  DISEASES    OF    TEE   STOMACH  AND   INTESTINES. 

is  the  most  frequent  cause  of  death.     The  remaining  cases  die  of 
cachexia. 

Treatment. — The  first  class  of  cases  are  treated  in  much  the  same 
manner  as  is  constipation.  In  the  second  and  third  forms  surgical 
interference  is  indicated  as  soon  as  the  diagnosis  is  made.  The  colon 
is  resected.  Thus  far  surgical  interference  has  not  been  attended 
with  great  success. 

Acute  Intestinal  Obstruction  (Intussusception). — Intussuscep- 
tion, according  to  Treves,  is  the  prolapse  of  one  part  of  the  intestine 
into  the  lumen  of  an  immediately  adjoining  part.  It  causes  more 
than  one-third  of  all  the  varieties  of  obstruction  of  the  gut. 

Varieties. — Invagination  of  the  gut  may  take  place  in  any  part, 
from  the  duodenum  to  the  rectum.     There  are  the  following  forms : 

Enteric. — The  enteric  form,  which  may  involve  any  part  of  the 
small  intestine,  but  which  most  commonly  involves  the  lower  part  of 
the  jejunum  or  the  ileum. 

Colic. — The  colic  form,  which  may  involve  any  portion  of  the 
colon. 

Ileoccecal.- — The  ileocgecal,  which  is  the  most  common  form. 

In  the  ileocsecal  variety  the  ileum  and  csecum  pass  into  the  colon, 
the  valve  preceding  and  forming  the  apex  of  the  intussusception.  In 
the  ileocolic  form,  the  valve  remains  stationary  and  the  ileum  passes 
into  the  colon.  In  the  latter  form  there  is  an  invagination  of  the 
csecum  and  colon,  of  a  secondary  character. 

Etiology.- — Xothnagel  demonstrated  that  intussusception  is  caused 
by  irregular  muscular  action  in  the  wall  of  the  intestine;  in  acute 
intussusception  this  is  of  a  spasmodic  character.  In  50  per  cent,  of 
the  cases  little  is  known  of  the  exciting  cause. 

Diarrhoea,  the  various  forms  of  enteritis,  polypi,  and  diverticula, 
improper  food,  traumatism,  and  exposure  to  cold,  have  all  been 
regarded  as  exciting  causes.  Typhoid  fever  and  pertussis  have  been 
complicated  or  followed  by  intussusception.  I  have  recently  seen  a 
case  following  typhoid  fever  in  a  boy  three  years  old. 

Meckel's  diverticulum  and  the  appendix  have  been  the  cause  and 
seat  of  intussusception.  In  the  latter  case  the  inverted  appendix 
caused  ileocsecal  intussusception. 

Frequency. — Intussusception  is  more  common  in  males  than  in 
females.  The  disproportion  diminishes  after  the  first  year  of  life. 
Fifty  per  cent,  of  all  the  cases  occur  before  the  tenth  year,  and  chiefly 
in  individuals  who  are  not  in  good  physical  condition  (Treves).  In 
the  cases  that  I  have  seen,  the  infants  were  not  noticeable  for  being 
in  previous  delicate  health  or  may  have  been  robust  infants  at  the 
breast  in  whom  there  has  been  a  previous  history  of  intestinal 
indigestion. 


DISEASES   OF    THE   STOMACH  AND   INTESTINES.  543 

The  youngest  case  I  have  met  was  five  and  a  half  months  of  age. 
This  infant  was  breast  fed,  had  suffered  with  colic,  and  had  had  green 
movements  from  birth;  there  was  an  ileocsecal  invagination  eight 
inches  in  length. 

Symptoms." — The  onset  is  sudden  in  75  per  cent,  of  the  cases ;  in 
the  colic  and  rectal  varieties  it  may  be  gradual.  In  many  cases  the 
disease  makes  its  appearance  while  the  infant  is  nursing  or  during 
sleep.  The  patient,  being  attacked  with  pain,  suddenly  awakes  from 
sleep  with  a  cry  and  begins  to  vomit ;  on  the  same  day  or  the  follow- 
ing day  a  bloody  movement  appears,  the  amount  of  f  seces  being  small. 
In  a  few  cases  there  are  no  fsecal  evacuations.  If  the  case  is  progres- 
sive, the  pain  returns  in  paroxysms,  the  hemorrhagic  movements  are 
repeated,  and  the  vomiting  keeps  pace  with  the  increase  of  the  obstruc- 
tion. The  general  condition  of  the  patient  grows  worse ;  apathy  and 
collapse  ensue.  I  have  seen  cases  begin  with  a  mild  diarrhoea ;  the 
pain  suddenly  appears,  and  also  the  hemorrhages  from  the  bowel,  the 
infant  at  once  going  into  collapse. 

There  is  apathy  due  to  intestinal  intoxication  from  which  it  is 
difficult  to  rouse  the  patient.  If  the  case  continues  to  progress  with- 
out relief  the  movements  become  frequent,  exhaustion  increases,  and 
finally  death  from  asthenia  results.  The  pain  is  great  at  the  onset, 
usually  reaches  its  maximum  intensity  within  a  short  time,  and  then 
gradually  subsides.  It  is  of  a  paroxysmal  character  and  is  colicky 
during  the  advance  of  the  invagination;  as  adhesion  takes  place  or 
gangrene  occurs  it  diminishes.  The  intervals  between  the  paroxysms 
of  pain  are  at  first  of  considerable  length ;  later  they  become  shorter. 
The  pain  is  most  severe  in  the  ileocsecal  form,  and  is  in  all  forms 
caused  by  irregular  intestinal  peristalsis. 

Vomiting. — Vomiting  is  not  so  prominent  a  symptom  as  in  other 
forms  of  intestinal  obstruction  (Treves).  In  75  per  cent,  of  the 
cases  it  comes  on  early  with  or  directly  after  the  pain.  It  may  not 
recur  for  hours.  In  a  child  taken  with  sudden  pain  of  a  colicky  char- 
acter, vomiting,  and  bloody  stools,  the  vomiting  recurred  only  twice 
within  twenty-four  hours.  It  is  apt  to  be  less  violent  as  long  as  there 
is  not  complete  obstruction  of  the  gut;  in  other  words,  it  is  more 
marked  in  those  cases  in  which  no  faeces  pass.  As  long  as  the  pain 
recurs  in  paroxysms  (progression  of  the  intussusceptum)  the  vomit- 
ing is  not  apt  to  be  marked.  The  vomited  matter  is  composed  of  the 
stomach  contents  and  is  biliary;  stercoraceous  vomiting  was  found 
late  in  only  25  per  cent,  of  Leichtenstern's  cases;  Gibson  also  found 
it  to  be  rare  and  late.  If  stercoraceous  vomiting  was  present,  it 
appeared  from  the  fourth  to  the  seventh  or  to  the  fourteenth  day.  In 
the  case  referred  to,  in  the  infant  of  five  and  one-half  months,  it 
appeared  during  the  first' twelve  hours  of  the  disease. 


544  DISEASES   OF    THE   STOMACH  AND   INTESTINES. 

The  condition  of  the  bowel  is  important.  It  is  generally  stated 
that  constipation  occurs  from  the  outset ;  this  is  not  universally  true. 
Cases  in  which  constipation  exists  throughout,  that  is  to  say,  in  which 
no  fseces  whatever  are  passed,  are  not  common,  and  form  only  30  per 
cent,  of  the  total  number.  Diarrhoea  is  the  common  condition  at  the 
outset;  as  the  obstruction  increases,  the  amount  of  faeces  in  the  stools 
diminishes,  and  finally  only  mucus  and  blood  are  passed. 

The  most  important  symptom  in  connection  with  the  bowels  is 
hemorrhage.  Hemorrhage  from  the  bowel,  in  connection  with  pain 
and  other  abdominal  symptoms,  is  considered  by  Gibson  as  pathog- 
nomonic. It  was  present  in  80  per  cent,  of  the  cases  tabulated  by 
Leichtenstern.  As  a  rule  it  is  considerable.  It  is  said  by  Treves 
to  have  been  in  some  cases  so  great  as  to  cause  death.  The  blood  and 
faeces  have  a  cadaveric  odor,  which,  however,  is  not  always,  as  some 
writers  affirm,  a  sign  of  gangrene.  I  have  perceived  this  odor  in  an 
intussusception  which  operation  showed  not  to  be  the  seat  of  gan- 
grene.    It  is  caused  by  decomposition  of  the  blood  in  the  gut. 

The  temperature  is  normal,  slightly  subnormal,  or  slightly  ele- 
vated. There  may  be  a  slight  elevation  of  temperature  without  peri- 
tonitis. The  quantity  of  urine  may  as  in  other  forms  of  intestinal 
obstruction  be  diminished. 

Tenesmus. — Tenesmus  is  present  in  55  per  cent,  of  the  cases;  it 
depends  more  or  less  on  the  presence  of  the  intussusception  in  the 
rectum.  It  is  usually  an  early  symptom  in  the  rectal  form,  and  is 
more  common  in  the  ileocascal  variety  than  in  the  enteric. 

The  abdomen  is  not  at  first  distended;  it  may,  on  the  contrary, 
be  retracted;  if  tympanites  occurs  at  all,  it  does  so  late  and  in  the 
presence  of  a  general  peritonitis.  Palpation  of  the  abdomen  is  at 
fij-st  well  borne,  but  after  a  time  there  is  sensitiveness. 

Tumor.- — A  tumor  felt  through  the  abdominal  wall  or  in  the 
rectum  is  of  the  greatest  value  in  the  diagnosis.  It  cannot  be  felt 
if  the  intussusception  is  in  the  hepatic  or  splenic  flexure  of  the  colon. 
It  is  variable  in  distinctness,  and  is  most  frequently  felt  in  the  region 
of  the  descending  colon  or  of  the  sigmoid  flexure. 

Infants  below  one  year  of  age  who  were  brought  under  my  obser- 
vation early  presented  a  distinct  tumor  in  the  region  of  the  ascending 
and  transverse  colon  if  the  intussusception  was  ileocsecal.  Gentle 
superficial  palpation  is  more  effective  in  infants  than  rnde  examina- 
tion; the  latter  is  apt  to  cause  crying  and  abdominal  rigidity.  It  is 
hard  and  resistant,  and  rarely  more  than  six  inches  long.  It  is  often 
said  to  be  sausage-shaped,  but  the  statement  is  misleading.  The 
tumor  is  rarely  felt  in  the  ileocsecal  region,  for  the  reason  that  the 
intussusception  in  this  locality  is  small,  and  is  that  of  a  small  gut 
inside  of  a  large  one.     In  one-third  of  the  cases  the  rectum,  if  exam- 


DISEASES   OF   THE   STOMACH  AND  INTESTINES.  545 

ined,  shows  the  presence  of  the  intussusceptum.  The  rectal  tumor  is 
commonly  found  in  children,  because  in  them  the  colon  is  mobile. 
In  very  early  cases  I  have  not  found  a  rectal  tumor.  The  intestine 
may  reach  the  anus  as  early  as  the  second  day,  the  average  time  being 
the  seventh  day.  It  may  protrude  from  the  anus  from  three  to  eight 
inches,  and  may  be  in  a  gangrenous  state;  under  these  conditions  it 
has  been  mistaken  for  a  polypus  or  hemorrhoid. 

Prognosis.  — As  regards  duration,  there  are  three  varieties  of  intus- 
susception— the  ultra  acute,  the  acute,  and  the  subacute.  The  ultra 
acute  cases  are  exceedingly  rare.  Leichtenstern  found  only  5  of  this 
form  in  a  total  or  7269  cases ;  4  of  the  5  occurred  in  infants  less  than 
a  year  old.     All  were  fatal. 

The  rate  of  mortality  in  intussusception,  excluding  the  ultra  acute 
forms,  varies  as  given  in  the  statements  of  different  authors.  Gib- 
son's statistics  place  the  mortality  at  53  per  cent.  It  varies  with  the 
age  of  the  patient,  the  duration  of  the  disease  before  operating,  and 
the  success  in  reducing  the  intussusception.  Intussusception  is  ex- 
tremely fatal  in  infants  under  the  first  year. 

If  the  diagnosis  is  made  early  I  have  found  the  prognosis  in 
infants  below  one  year  of  age  not  as  bad  as  some  writers  would  lead 
us  to  suppose.  According  to  Treves,  the  mortality  under  one  year 
of  age  is  80  per  cent.  On  the  other  hand,  if  we  study  the  cases  as 
Gibson  has  done,  we  find  that  the  cases  operated  on  during  the  first 
day  of  the  disease  had  a  mortality  of  41  per  cent. ;  those  on  the  fourth 
day,  72  per  cent.  The  reducible  cases  showed  a  mortality  of  38  per 
cent. ;  the  irreducible,  of  88  per  cent. 

Diagnosis. — From  the  studies  made  by  Gibson,  it  may  be  seen 
that,  in  children,  a  bloody  discharge  with  abdominal  pain  of  a 
paroxysmal  nature  is  almost  pathognomonic  of  intussusception.  The 
presence  of  a  tumor  fixes  the  diagnosis  absolutely.  Fsecal  vomiting 
is  of  very  little  value  as  a  diagnostic  sign.  It  is  very  infrequent,  and 
is  in  any  case  present  only  late  in  the  disease,  when  occlusion  of  the 
gut  has  occurred.  ' 

If  enteritis  exists  in  a  young  infant,  it  is  often  difficult  in  the 
absence  of  any  abdominal  or  rectal  tumor  to  make  a  diagnosis.  The 
course  of  the  case  will  guide  the  physician.  In  dysentery  the  hemor- 
rhage from  the  bowel  is  not  great ;  it  is  composed  of  blood-tinged 
mucus  with  fseces.  Cases  of  scurvy  may  simulate  intussusception  if 
bloody  discharges  appear  with  the  intestinal  movements.  In  these 
cases  the  amount  of  blood  voided  per  rectum  is  fully  as  great  as  in 
cases  of  intussusception.  In  scurvy,  however,  there  is  faecal  matter 
in  the  movements,  in  the  cases  coming  under  observation  of  the  author, 
as  also  signs  of  scurvy,  such  as  tenderness  of  the  bones  and  spongy, 
bleeding  gums.  Appendicitis  has  been  mistaken  for  intussusception. 
35 


546  DISEASES   OF    TEE   STOMACH  AXD   INTESTINES. 

It  frequently  occurs  with  it,  aud  thns  obscures  the  picture.  Peri- 
tonitis can  hardly  be  mistaken  for  intussusception.  In  peritonitis 
the  pain  is  continuous  and  there  is  tympanites,  but  no  bloody  dis- 
charge. Peritonitis  is.  however,  a  late  symptom.  Tuberculous  peri- 
tonitis is  sometimes  mistaken  for  intussusception.  In  tuberculous 
peritonitis  the  symptoms  are  not  progTessive,  and  also  there  is  not 
likely  to  be  a  bloody  discharge. 

The  case  following  typhoid  fever,  to  which  I  referred,  simulated 
a  hemorrhage  from  a  typhoidal  ulcer.  A  careful  examination  under 
an  ansesthetic  cleared  up  the  case.  In  complete  relaxation  under 
ansesthesia,  a  tumor  could  be  felt  in  the  csecal  region  of  the  ascend- 
ing colon.  The  result  of  examination  was  verified  by  operation.  In 
all  doubtful  cases  in  which  the  restlessness  of  the  child  interferes 
with  a  careful  examination  an  ansesthetic  should  be  given.  There 
is  a  characteristic  condition  which  in  some  cases  can  be  detected  by 
examination.  As  the  finger  is  inserted  into  the  anus  the  rectum  is 
felt  to  be  inflated.  This  is  due  to  traction  on  the  gut  by  the  invagi- 
nation. I  have  found  this  inflated  state  of  the  rectum  in  two  infants 
suffering  from  intussusception. 

Spontaneous  Cure. — There  is  little  doubt  of  the  possibility  of  spon- 
taneous recovery  in  invagination;  such  cases  have  been  seen  by  com- 
petent observers.  Henoch  has  seen  typical  intussusception  retrograde 
and  the  patient  recover.  There  is  another  mode  of  recovery  which 
occurs  in  cases  of  irreducible  intussusception :  the  intussusceptum 
sloughs  off  and  is  passed  per  anum.  This  occurred  in  43  per  cent, 
of  the  unrelieved  cases  (Leichtenstern),  but  in  40  per  cent,  of  these 
the  patient  succumbed  to  general  sepsis  with  or  without  peritonitis  or 
to  subsequent  obstruction  of  the  gut  from  swelling  after  the  gan- 
grenous portion  had  sloughed  away,  Henoch  reported  a  case  of  this 
kind. 

Treatment, — The  diagnosis  of  intussusception  once  made,  the  case 
is  one  for  surgical  interference.  The  sooner  surgical  treatment  is 
begun,  the  better  the  chances  of  recovery.  Injections  of  air,  gas  under 
pressure,  and  enemata  of  water  and  oil  have  been  tried,  with  some 
measure  of  success.  Their  use,  however,  delays  the  radical  treatment 
and  reduces  the  chances  of  ultimate  recovery,  and  apparent  improve- 
ment frequently  gives  way  to  an  exacerbation  of  symptoms.  Surgical 
aid  then  comes  too  late. 

The  objections  to  the  treatment  by  injection  are  as  follows:  the 
intestine  is  viable  in  these  cases,  and  is  liable  to  be  ruptured  by  injec- 
tion of  gas  or  air  under  pressure ;  an  enema  of  water  under  only  four 
feet  of  pressure  has  been  known  to  produce  this  result.  Snow  published 
a  case  in  which  an  injection  of  oil  was  made ;  postmortem  the  oil  was 
found  above  the  point  of  obstruction.     The  enema  may  thus  pass 


DISEASES    OF    THE   STOMACH  AND   INTESTINES.  547 

through  the  lumen  of  the  gut  without  relieving  the  intussusception. 
Enemata  should  be  given,  if  at  all,  during  the  first  24  hours,  and 
should  he  allowed  to  flow  into  the  rectum  under  very  low  pressure. 
The  amount  of  fluid  varies ;  certainly  not  more  than  a  quart  should 
be  given.  The  fluid,  a  saline  solution  at  100°  F.  (37.7°  C),  is 
allowed  to  remain  in  the  rectum  for  ten  minutes,  the  patient  being 
under  an  anaesthetic.  A  Davidson  syringe  should  not  be  used.  The 
ordinary  fountain  bag  irrigator  is  best  for  this  purpose.  If  one 
enema  fails  and  the  diagnosis  is  moderately  certain  there  should  be 
no  delay  in  seeking  surgical  assistance. 

Appendicitis  (Perityphlitis;  Paratyphlitis) — Anatomical  Pecul- 
iarities.— Vallee  examined  the  appendix  in  100  infants  and  children 
postmortem.  He  found  that  in  fully  75  per  cent,  the  csecum  is  situ- 
ated above  the  anterior  superior  spine,  on  the  right  side,  a  position 
higher  than  that  occupied  in  the  adult.  It  is  above  the  plane  of  the 
anterior  superior  spine  of  the  ileum,  is  almost  5  centimetres  long,  and 
has  a  general  longitudinal  ascending  or  descending  direction.  In 
one  case  the  appendix  was  situated  entirely  to  the  left  of  the  median 
line,  there  being  no  transposition  of  the  other  viscera.  Knowledge 
of  these  facts  is  of  importance  in  the  examination  for  the  appendix  in 
conditions  of  disease.  I  have  frequently  succeeded  in  palpating  the 
normal  appendix  at  one  side  of  the  csecum.  It  is  felt  as  a  cylindrical 
body  having  the  diameter  of  a  quill. 

Acute  Appendicitis. — Frequency. — Although  the  statistics  show- 
ing the  frequency  of  appendicitis  in  infancy  and  childhood  vary  with 
the  number  of  cases  collected  by  each  author,  the  combined  statistics 
of  Matterstock,  Fitz,  Sonnenburg,  and  ISTothnagel,  show  that  the  dis- 
ease is  not  very  frequent  before  the  tenth  year.  Only  8  per  cent,  of 
the  cases  occur  at  this  age.  It  may  occur  in  early  infancy.  Savage 
records  a  case  in  an  infant  two  months  old;  Demme  also  records  a 
case  in  a  very  young  infant. 

The  literature  shows  occasional  cases  at  all  periods  of  infancy. 
Among  the  cases  collected  and  tabulated  from  the  service  of  my  col- 
leagues, Grerster  and  Lillienthal,  at  the  Mount  Sinai  Hospital,  there 
is  one  of  an  infant  one  year  of  age.  Of  50  cases  of  appendicitis  in 
children  taken  from  the  service  of  these  surgeons,  1  occurred  in  an 
infant  one  year  of  age,  17  from  the  third  to  the  sixth  year,  and  32 
from  the  sixth  to  the  tenth  year  of  life.  Thus  in  a  statistical  collec- 
tion of  cases  occurring  in  children,  only  one-third  occurred  before  the 
sixth  year  of  life. 

Varieties. — The  forms  of  the  disease  are  the  same  as  in  the  adult 
subject.  The  perforative  form  seems  to  be  the  most  common  among 
children.  Thus  of  50  cases  coming  to  the  hospital  for  operation,  31 
were  perforative  with  or  without  abscess,  9  were  of  the  gangrenous 


548  DISEASES   OF   TEE   STOMACH  AND   INTESTINES. 

variety,  and  6  of  the  catarrlial  form.  It  will  thus  be  seen  that  in 
children  the  tendency  in  this  disease  as  in  others,  such  as  pleurisy,  is 
toward  suppuration  and  the  formation  of  abscess. 

Ssonptoms. — The  symptoms  will  vary  with  the  variety,  whethei" 
catarrhal,  perforative,  or  gangrenous. 

Catarrhal  Form.- — In  the  catarrhal  form  the  patient  is,  after 
some  indiscretion  in  diet,  seized  with  colicky  abdominal  pain,  vomit- 
ing, and  some  fever.  In  other  cases  the  children  simply  complain  of 
pain  which  is  not  sufficiently  severe  to  prevent  their  being  up  and 
about.  The  pain  is  not  always  located  by  the  patient  in  the  appendix. 
When  the  patients  are  in  the  recumbent  posture,  the  right  knee  may 
be  flexed  and  the  thigh  flexed  on  the  abdomen ;  when  they  walk,  they 
do  so  in  a  bent  position,  favoring  the  affected  side.  Physical  exami- 
nation reveals  a  localized  resistance  or  tenderness  in  the  right  iliac 
fossa.  In  some  cases  there  is  distention  of  the  caecum  with  faeces,  in 
others  I  have  felt  the  appendix  and  the  caecum  matted  together  in  a 
mass  of  the  size  of  the  index  finger. 

The  pain  is  not  always  referred  to  the  iliac  fossa,  but  may  be 
distinctly  located  around  the  umbilicus  or  over  the  lower  part  of 
the  abdomen. 

It  may  not  always  be  possible  to  palpate  the  appendix,  which  may 
be  behind  the  caecum.  Under  such  conditions  no  intumescence  will 
be  found.     Z\IcBurney's  point  will  be  considered  in  the  diagnosis. 

The  history  of  many  of  the  catarrhal  cases  is  one  of  recovery 
under  careful  treatment.  The  fever  subsides  or  may  never  have  been 
above  101°  F.  (38.3°  C.)  ;  the  pain  also  subsides,  and  in  from  a  few 
days  to  a  week  the  patient  is  apparently  well.  Attacks  of  this  kind 
may  recur. 

Perforative  or  Suppurative  Fo7'm. — In  the  perforative  or  suppu- 
rative form  the  symptoms  are  more  violent.  In  this  form  also  the 
onset  of  the  disease  seems  to  date  from  some  indiscretion  in  diet. 
The  patient  is  seized  with  sudden  sharp  pains  in  the  abdomen,  accom- 
panied by  vomiting,  fever,  and  rapidity  of  pulse.  The  pain  is  located 
either  in  the  upper  or  the  lower  part  of  the  abdomen,  or  in  a  few 
cases  in  the  right  iliac  fossa.  After  one  or  two  attacks  of  vomiting 
this  symptom  may  subside  and  not  recur  until  the  second  or  third 
day,  when  perforation  occurs.  Tympanites  occurs  early  and  may  set 
in  after  the  second  day  of  the  disease.  The  pain  and  tympanites 
cause  an  increase  in  the  respiratory  movements,  which  are  shallow. 
The  patients  lie  in  the  recumbent  posture.  The  escape  of  gas  and 
intestinal  contents,  if  perforation  occurs,  causes  a  disappearance  of 
the  liver  dulness,  with  peritonitis  and  a  formation  of  fluid  in  the 
peritoneal  cavity  with  a  movable  dulness  in  the  flanks  on  percussion. 
The  pulse  is  at  first  rapid  and  thready,  and  quickly  mounts  above 


DISEASES    OF    THE   STOMACH  AND   INTESTINES.  549 

120  after  perforation  has  occurred.  The  prostration  is  great,  and  in 
some  cases  of  a  septic  type  jaundice  is  present. 

Gangrenous  Form. — In  the  gangrenous  form  the  symptoms  are 
very  similar  to  those  of  the  perforative  form,  but  are  very  much  inten- 
sified. It  is  not  possible  to  tell  from  the  symptoms  whether  the  process 
is  gangrenous,  simply  perforative,  or  catarrhal  follov^^ed  by  abscess. 

Course. — In  both  the  perforative  and  the  gangrenous  cases  in  chil- 
dren as  in  the  adult,  localized  adhesions  may  form  with  a  small  or 
large  collection  of  pus  or  several  foci  of  pus.  In  other  cases  a  gen- 
eral peritonitis  follows  the  perforation.  In  children,  as  in  adults, 
the  moment  of  perforation  is  followed  by  a  temporary  fall  in  the 
temperature  and  a  cessation  in  the  pain  and  vomiting,  the  pulse,  how- 

FiG.  112. 


6'D,./,-.n,: 


Method  of  examination  of  the  region  of  the  appendix  vermiformis. 

ever,  continuing  rapid.  The  lull,  however,  is  of  short  duration,  and 
is  quickly  followed  by  an  increase  in  the  severity  of  the  symptoms. 

Diagnosis. — The  above  outline  gives  very  little  idea  of  the  great 
and  sometimes  insurmountable  difficulties  of  diagnosis  of  appendicitis 
in  young  children.  To  guard  against  error,  a  very  careful  routine 
should  be  followed.  The  patient  is  completely  undressed  and  lies  in 
the  recumbent  posture,  the  shoulders  being  slightly  raised.  The  phy- 
sician should  stand  or  sit  at  the  patient's  right.  The  contour  of  the 
abdomen  is  noted.  If  it  is  normal  and  not  distended,  there  is  prob- 
ably no  peritonitis.  The  abdomen  is  very  gently  palpated  in  different 
places  to  ascertain  if  there  is  distributed  or  localized  tenderness.  The 
left  palm  is  then  placed  underneath  the  right  loin,  and  with  the  palmar 
surface  of  the  fingers  of  the  right  hand  the  region  of  the  appendix  is 
gently  palpated  (Fig.  112). 

Superficial  palpation  is  practised  at  first.  The  hand  is  then 
depressed  deeper  into  the  iliac  fossa  in  search  of  resistance  or  tumor. 


550  DISEASES    OF    THE   STOMACH  AND   INTESTINES. 

The  intensity  of  the  pain  caused  bv  manipulation  is  carefully  gauged 
by  "\vatching  the  face  of  the  patient.  The  right  iliac  region  haying 
been  carefully  palpated,  rectal  exploration  should  be  made  in  all 
doubtful  cases.  This  is  necessary  in  the  cases  in  which  a  general 
tympanites  or  general  abdominal  tenderness  makes  the  diagnosis 
difficult.  With  the  well-oiled  index  finger  of  the  right  hand  the 
rectum  is  explored  as  high  up  as  possible.  In  young  children  this 
can  be  done  without  causing  pain  if  gentleness  and  caution  are  exer- 
cised. If  children  are  very  intractable,,  this  method  of  examination 
cannot  be  carried  out. 

Rectal  examination  is  exceedingly  dangerous  in  those  cases  in 
which  there  is  a  localized  abscess.  Any  careless  manipulation  may 
break  up  the  delicate  adhesions  between  the  coils  of  gut  and  evacuate 
the  abscess  into  the  general  peritoneal  cavity. 

The  following  points  are  important  in  the  diagnosis : 

Tympanites. — If  the  abdomen  is  distended  and  there  is  general 
pain  with  increase  of  the  number  of  respirations,  there  is  probably 
peritonitis  localized  or  diffuse.  In  the  latter  case  there  is  disappear- 
ance of  the  liver  dulness  if  the  tympanites  is  extreme. 

Percussion.- — Percussion  will  sometimes,  even  in  general  peri- 
tonitis, give  a  localized  dulness  in  the  right  iliac  fossa.  Localized 
pain  and  intumescence  or  a  localized  mass  in  the  right  iliac  fossa  are 
of  great  import. 

McBurney's  Point. — McBurney's  point  is  of  less  value  in  children 
than  in  the  adult.  In  children,  as  will  be  seen  from  Vallee's  work, 
the  appendix  is  situated  higher  than  in  the  adult,  and  McBurney's 
point  is  therefore  too  low  for  palpation.  Some  children  complain  of 
epigastric,  others  of  umbilical  pain,  which  is  not  so  distinctly  localized 
as  in  the  adult. 

Fever. — The  fever  is  of  little  value,  there  being  nothing  charac- 
teristic in  the  curve.  The  temperature  may  be  normal  or  in  severely 
septic  cases  slightly  raised.  After  perforation,  the  temperature  be- 
comes subnormal,  as  it  does  in  the  adult. 

Tuberculous  Peritonitis. — Appendicitis  in  children  may  simulate 
tuberculous  peritonitis.  In  the  latter  disease  there  is  sometimes 
severe  pain  of  the  colicky  variety.  Tuberculous  peritonitis  and  ap- 
pendicitis may  be  coincident. 

Pain.— Pain  in  appendicitis  resembles  very  closely  that  in  gastro- 
enteritis and  dysentery.  Griffith  has  published  2  cases  of  appendi- 
citis in  children  who  had  entero-colitis  at  the  same  time. 

Perinephritic  Abscess. — I  have  had  one  case  in  which  a  peri- 
nephritic  abscess  simulated  an  appendicitis.  The  contrary  may  also 
occur.  Appendicular  abscess  may  simulate  a  coxalgia  with  abscess. 
I  have  seen  a  few  cases  of  typhoidal  affection  of  the  appendix  which 


DISEASES    OF    THE   STOMACH  AND   INTESTINES.  551 

for  a  few  days  simulated  an  appendicitis  very  closely,  so  as  to  mis- 
lead the  surgeon  into  operating  upon  them.  Appendicitis  with  in- 
vagination of  the  appendix  into  the  csecum  is  a  rare  condition,  as  is 
also  intussusception  with  appendicitis.  In  the  typhoidal  cases,  a 
Widal  reaction  may  be  obtained,  and  mil  be  of  assistance  in  diag-nosis. 
Care  should  be  taken  that  a  perforating  typhoidal  ulcer  does  not 
escape  diagnosis.  Intussusception  will  give  the  characteristic  symp- 
toms of  that  condition. 

Lobar  Pneumonia. — I  have  seen  cases  of  lobar  pneumonia  of  the 
lower  lobe  of  the  right  lung,  in  which  the  pleuritic  pain  radiated 
down  the  right  side  into  the  iliac  fossa.  There  were  also  epigastric 
pain  and  vomiting  at  the  onset  of  the  disease.  The  excessive  rapidity 
of  the  respirations,  the  marked  dyspnoea,  and  absence  of  tympanites 
and  pain  on  deep  pressure  in  the  region  of  the  appendix,  led  me  to 
examine  the  lung. 

Prognosis. — Of  the  50  hospital  cases  which  I  have  tabulated  above, 
only  3  recovered  without  operation ;  they  were  of  the  catarrhal 
variety.  These  figures  give  no  accurate  idea  of  the  proportion  of 
recoveries  made  under  careful  and  conservative  treatment  in  private 
practice. 

The  mortality  in  the  cases  operated  upon  was  35  per  cent.  The 
rate  is  not  high  considering  that  many  cases  came  under  the  knife 
later  than  would  have  been  the  case  in  private  practice.  On  the 
other  hand,  it  should  be  remembered  that  the  rate  of  mortality  is  also 
influenced  by  the  nature  of  the  infection  and  the  power  of  resistance 
of  the  patient.  Thus  cases  with  a  gangrenous  appendix  died  although 
operated  upon  on  the  second  day;  others  of  the  same  kind  recovered 
although  the  disease  had  lasted  from  four  to  seven  days  before  opera- 
tion. Some  perforative  cases  died  on  the  second  or  third  day  of  the 
disease,  while  others  recovered  although  operated  upon  from  six  to 
twelve  days  after  the  onset  of  symptoms.  Gangrenous  cases  in  this 
statistical  table  in  children  show  a  lower  rate  of  mortality  than  those 
cases  in  which  the  appendix  perforates,  forms  an  abscess,  and  causes 
general  peritonitis. 

Chronic  Appendicitis. — This  form  of  appendicitis  occurs  in  older 
children.  The  symptoms  are  frequently  mistaken  for  those  of  dys- 
pepsia. The  history  is  much  the  same  as  in  the  adult.  A  child 
otherwise  in  good  health  has  attacks  during  which  there  is  abdominal 
pain  not  of  great  severity,  accompanied,  at  times,  by  vomiting,  but 
which  may  last  for  a  few  hours  and  disappear,  leaving  the  patient 
well.  The  pain  is  very  rarely  referred  to  the  appendix ;  it  is  abdom- 
inal, the  umbilical  region  being  generally  indicated  as  the  seat  of  dis- 
comfort. The  temperature  may  reach  100°  F.  (37. Y°  C.)  ;  the  pulse 
in  a  child  of  eight  years  was  96  and  regular.     There  is  no  vomiting 


652  DISEASES   OF   THE   STOMACH  AND   INTESTINES. 

and  no  prostration.  The  pain  is  sufficiently  severe  to  make  the  patient 
wish  to  lie  down ;  it  is  not  excessive  when  the  appendix  is  palpated. 
The  bowels  are  regular.  The  cases  may  in  the  intervals  between  the 
attacks  show  a  slight  intumescence  in  the  region  of  the  appendix,  but 
nothing  is  felt  in  the  rectum.  The  signs  in  the  interval  may  be  very 
indefinite  or  quite  distinct.  The  caecum  and  appendix  are  felt  to  be 
matted  together. 

Three  cases  in  which  there  had  been  repeated  attacks  extending 
over  a  period  of  from  one  to  two  years,  were  operated  upon  for  me 
by  leading  surgeons.  The  patients  were  girls  between  the  ages  of 
six  and  eight  years.  In  each  case  there  was  evidence  of  a  chronic 
catarrhal  process.  In  one  case  the  appendix  contained  a  faecal  cal- 
culus, in  another  there  were  constricting  adhesions. 

Treatment.^ — The  treatment  of  both  acute  and  chronic  appendicitis 
in  infants  and  children  does  not  differ  from  that  followed  in  the  adult 
subject. 

Rectum. — In  infants  a  large  portion  of  the  rectum  is  situated  in 
the  abdominal  cavity  rather  than  in  the  pelvis.  In  infants  and  chil- 
dren it  has  three  curves — one  lateral  and  two  anteroposterior.  The 
gut  is  nearly  straight  and  occupies  a  more  or  less  vertical  position, 
hence  the  frequency  of  prolapse.  The  attachment  of  the  rectum  to 
the  surrounding  parts  is  not  extended  as  high  in  children  as  in  adults, 
hence  the  rectum  is  more  liable  to  be  pushed  out.  The  rectum  of  the 
newborn  infant  may  be  divided  into  three  parts.  The  first  lies  in 
front  of  the  sacrum  and  ends  at  the  lower  end  of  the  bone ;  the  second 
is  short,  and  in  this  respect  differs  from  the  adult  gut,  being  also  more 
vertical ;  the  third  portion  is  long,  and  extends  downward,  and  some- 
what backward.  The  second  portion  being  short,  when  the  rectum 
is  distended,  the  gut  is  straightened  out  and  the  whole  rectum  extends 
downward  and  backward  (Symington).  All  these  data  are  of  impor- 
tance in  applying  methods  of  therapy  (enteroclysis,  etc.)  to  this  organ. 

Prolapsus  Ani. — Prolapsus  ani  is  a  condition  frequently  met  with 
in  infants  and  children.  It  may  amount  only  to  an  eversion  of  the 
mucous  membrane.  There  is  in  some  cases  a  complete  descent  of 
part  of  the  rectum,  which  protrudes  from  the  anus  to  the  length  of 
one  or  two  inches. 

Etiology. — The  etiology  of  this  condition  is  obscure.  It  evidently 
occurs  only  in  cases  in  which  the  pelvic  attachments  of  the  lower 
bowel  are  lax.  It  is  favored  by  anatomical  conditions  elsewhere 
mentioned.  It  is  seen  in  children  who  are  constipated,  in  those  who 
suffer  from  diarrhoea,  and  also  in  those  whose  movements  are  not 
normal.  Any  abnormal  condition  in  the  neighboring  organs,  such  as 
the  bladder  and  urethra  (stone),  may  cause  excessive  straining  and 
consequent  prolapse  of  the  gut.     A  rectal  polypus  may  cause  prolapse. 


DISEASES    OF    THE   STOMACH  AND   INTESTINES.  553 

Symptoms. — In  some  cases  the  only  symptom  is  the  appearance  of 
a  small  quantity  of  mucus  and  blood  on  the  diaper  with  each  move- 
ment; in  these  cases  the  prolapse  returns  spontaneously.  In  other 
cases  the  bowel  descends  to  the  extent  of  one  or  two  inches  with  the 
movement,  and  remains  prolapsed.  If  a  polypus  of  the  lower  part 
of  the  rectum  is  the  cause  of  the  prolapse,  it  is  seen  protruding  from 
the  prolapsed  portion. 

Treatment. — The  iirst  step  is  to  replace  the  protruding  gut.  The 
gut  is  anointed  with  olive  oil  or  vaseline  and  gently  replaced  with  a 
towel.  The  movements  are  so  regulated  by  diet  and  cathartics  that 
the  stools  are  passed  without  straining.  Three  times  daily  a  supposi- 
tory containing  grains  ij  to  iij  (0.12  to  0.2)  of  tannic  acid  is  placed 
in  the  lower  bowel.  While  the  movements  are  being  passed  the  pa- 
tient is  kept  in  the  recumbent  posture  on  a  bedpan.  This  treatment  is 
frequently  successful.  In  other  cases,  the  buttocks  are  drawn  together 
by  adhesive  straps  and  the  child  is  allowed  to  pass  movements  thus 
strapped.  Cocaine  and  strychnine  are  used  both  in  suppositories  and 
hypodermically.  The  protruding  portion  is  painted  with  cocaine. 
These  measures  have  their  failures  and  successes.  The  only  satis- 
factory method  is  that  first  advised — of  a  strict  diet,  the  recumbent 
posture  at  stool,  and  the  astringent  suppository.  The  Paquelin 
cautery  is  sometimes  employed  to  cauterize  the  mucous  membrane. 
The  danger  in  this  method  is  the  substitution  of  a  traumatic  stricture 
of  the  anus  for  the  comparatively  harmless  prolapse.  Application  of 
the  pure  stick  of  silver  nitrate  to  the  anus  twice  a  week,  has  given 
good  results.  If  a  polypus  of  the  rectum  is  the  cause  of  the  prolapse, 
the  growth  should  be  removed  by  surgical  means. 

Fissure  of  the  Anus.- — Fissure  of  the  anus  is  seen  in  syphilitic 
infants,  in  those  suffering  from  marked  constipation,  and  in  infants 
that  have  eczema  of  the  anus.  It  may  be  the  result  of  the  repeated 
introduction  of  the  hard  nozzle  of  an  enema  syringe.  The  fissure 
may  be  so  slight  as  to  be  only  a  line-like  tearing  of  the  mucous  mem- 
brane, or  may  consist  of  a  broad  ulcer  with  a  hard  granulating  base. 

Symptoms. — ^As  a  rule,  the  infants  are  constipated.  When  a 
movement  is  passed,  the  infant  cries  and  there  is  great  pain.  A  few 
drops  of  blood  are  passed  on  the  diaper. 

Diagnosis. — The  presence  of  a  fissure  of  the  anus  sometimes 
escapes  the  notice  of  the  physician.  If  there  is  a  history  of  the  above 
symptoms,  the  physician  should  place  the  infant  on  a  table,  grasp  the 
buttocks  with  the  palm  of  the  hands  and  separate  them  forcibly  with 
the  thumb.  The  anus  is  thus  everted,  and  if  a  fissure  is  present  it 
will  at  once  become  apparent. 

Treatment. — A  small  fissure  is  sometimes  very  successfully  treated 
by  regulating  the  bowels.     It  is  touched  with  a  10  per  cent,  solution 


554  DISEASES    OF    THE    STOMACH  AND   INTESTINES. 

of  silver  nitrate  once  a  day.  In  the  severe  cases  silver  applications 
will  not  avail;  forcible  dilatation  of  the  rectum  by  means  of  the 
thumbs  must  be  resorted  to.  This  procedure  not  only  cures  the  fissure, 
but  is  also  an  effectual  remedy  for  the  accompanying  constipation. 

Spasm  of  the  Anus.- — -Cases  of  nervous  spasm  of  the  sphincter 
ani  occur  in  infants.  The  infant  is  constipated  and  cries  at  each 
movement.  There  is  no  bleeding,  nor  does  examination  reveal  any 
fissure,  but  only  marked  contracture  of  the  anal  opening.  In  these 
cases  it  is  almost  impossible  in  an  examination  to  bring  down  the 
upper  part  of  the  anal  gut. 

The  remedy  is  to  regulate  the  bowels.  If  by  this  means  success 
in  overcoming  the  spasm  is  not  attained,  forcible  dilatation  is  the 
only  resource. 

Proctitis. — Apart  from  the  membranous  and  catarrhal  forms  of 
proctitis,  which  occur  with  similar  conditions  of  the  intestine,  the 
only  form  which  is  of  interest  is  the  gonorrhoeal.  This  occurs  as  a 
complication  of  vulvovaginal  gonorrhoeal  inflammation.  In  these 
cases  the  introduction  of  the  gonococcus  from  the  vagina  into  the  gut 
has  occurred  through  careless  thermometry  or  the  giving  of  enemata 
without  previous  cleansing  of  the  parts.  The  disease  is  very  painful 
and  at  the  same  time  trying  to  the  infant  or  child.  With  the  dis- 
charge of  pus  from  the  anus  there  are  tenesmus  and  a  bloody  discharge 
with  the  movements.     The  purulent  discharge  shows  gonococci. 

Treatment. — The  treatment  consists  in  the  injection  of  protargol 
solutions,  2  per  cent.,  at  a  temperature  of  105°  to  108°  F.  (40.5°  to 
42.5°  C),  into  the  rectum  twice  daily.  The  bowels  are  regulated. 
Suppositories  of  tannin  or  tannigen  are  also  of  value  and  give  great 
relief;  one  containing  grains  iij  (0.18)  is  given  per  rectum  twice 
daily.  In  the  later  stages  it  may  be  necessary  to  paint  the  lower  bowel 
with  a  very  weak  solution  (0.5  per  cent.)  of  silver  nitrate. 

Polypus  of  the  Rectum. — Polypus  of  the  rectum  is  not  rare  in 
childhood,  but  is  not  often  seen  in  infancy.  It  occurs  most  frequently 
from  the  third  to  the  seventh  year  of  life.  The  polypi  are  adenomata. 
I  have  examined  several,  and  have  found  them  to  have  the  structure 
described  by  Baginsky.  They  may  be  single  or  multiple,  usually 
have  a  pedicle,  but  may  be  attached  to  the  wall  of  the  gut  by  a  broad 
base.  As  a  rule  they  are  situated  on  the  posterior  wall  of  the  rectum 
seven  or  eight  centimetres  above  the  anal  ring,  but  may  be  on  the 
anterior  wall.  In  most  cases  the  polypi  exist  here  only,  but  I  have 
seen  them  higher  up  in  the  gut,  and  in  one  case  in  a  child  of  five  years 
from  whom  several  rectal  polypi  had  previously  been  removed,  I 
diagnosed  a  number  in  the  descending  colon.  In  this  case  lapa- 
rotomy and  incision  of  the  gut  proved  the  diagnosis  to  have  been 
correct.     The  polypi  may,  if  they  become  numerous,  assume  a  malig- 


INTESTINAL    PABASITES.  555 

iiant  character;  this  is  especially  true  of  the  growths  with  a  large, 
hroad  intestinal  base. 

Symptoms. — The  characteristic  symptom  is  intermittent  hemor- 
rhages from  the  gut,  which  may  be  profuse.  At  times  the  outer 
surface  of  the  movements  is  streaked  with  blood,  the  bowels  being 
constipated  or  normal,  with  an  occasional  mucous  diarrhoea.  If  the 
polypus  is  low  down,  there  is  straining  at  stool  with  prolapsus  of  the 
gut.  Many  of  the  children  thus  affected  are  pale,  have  a  pasty  hue 
of  the  skin,  and  show  evidences  of  lymphatism. 

Diagnosis. — Bleeding  from  the  bowel,  in  the  absence  of  other  symp- 
toms, should  at  once  suggest  the  necessity  of  digital  exploration  of 
the  lower  bowel.  If  a  polypus  is  not  found,  a  careful  palpation  of 
the  abdomen  made  when  the  patient  is  fasting  should  be  the  next 
procedure.  If  the  child  is  tractable  and  the  abdomen  soft,  it  may  be 
possible  in  rare  cases  to  feel  a  tumor  the  size  of  a  hazelnut  at  one 
side  of  the  umbilicus. 

Prognosis. — The  prognosis  is  good ;  removal  of  the  polypi  is  rarely 
followed  by  recurrence  of  symptoms,  even  in  cases  in  which  they  are 
situated  in  the  descending  colon.  If  they  are  removable  and  not  very 
numerous,  the  patient  recovers. 

Treatment. — If  the  polypus  is  low  down  and  pedunculated,  it  may 
easily  be  snared  with  or  without  the  aid  of  a  rectal  speculum.,  and 
crushed  or  ligated  off.  If  it  is  high  in  the  sigmoid  flexure,  the  anus 
should  be  dilated  and  the  growth  reached  by  means  of  a  speculum. 
In  cases  in  which  the  growth  is  in  the  colon,  laparotomy,  enterotomy, 
and  ligation  are  indicated. 

INTESTINAL    PARASITES. 

The  most  common  parasites  found  in  infants  and  children  are  the 
ISTematoda,  or  round  worms,  and  the  Cestoda,  or  tapeworms.  The 
round  worm  is  smooth  and  light  brown  or  reddish  in  color,  the  female 
being  larger  than  the  male.  The  eggs  are  found  in  the  stools ;  they 
are  from  0.05  to  0.06  mm.  in  diameter  and  are  surrounded  by  an  albu- 
minous envelope.  The  worm  is  several  inches  long.  Oxyuris  vermi- 
cularis  is  about  1  cm.  long,  the  male  having  a  length  of  4:  mm.  The 
eggs  measure  0.05  mm.  in  their  long  diameter. 

The  tapeworms  in  mature  state  consist  of  rectangular  segments. 
The  head  and  neck  are  called  the  scolex;  the  segments,  proglottides. 
The  worms  are  hermaphrodites.  The  solium  is  sometimes  several 
metres  long.  The  head  is  of  the  size  of  a  pin's  head,  with  a  pro- 
jecting proboscis  armed  with  booklets.  The  eggs  of  the  solium  are 
ovoidal,  0.3  mm.  in  diameter.  The  Taenia  mediocanellata  has  a  more 
cuboidal  head  without  booklets  (Fig.  113). 


556 


INTESTINAL    FABASITES. 


Diagnosis. — There  are  no  symptoms  which  can  be  traced  to  the 
presence  of  these  worms  in  the  gut.  If  they  increase  in  enormous 
numbers,  they  may  cause  symptoms  of  mechanical  obstruction. 
Without  the  presence  of  the  eggs  or  links  of  the  worm,  a  diagnosis 
is  not  possible.  Their  presence  is  made  known  by  the  passage  per 
anus  of  the  links  of  such  worms  as  the  tapeworm.  Round  worms 
may  also  pass  out  of  the  anus,  or  may  be  vomited  if  they  gain  access 
to  the  stomach.  Thread  worms  may  cause  excessive  pruritus,  and 
may  not  be  discovered  external  to  the  anus.  In  that  case  the  faeces 
should  be  carefully  examined  for  the  eggs  of  the  worms. 

Fig.  113. 
1  2  3  4 


1.  Oxyuris  vermicularis,  pin  worm,  natural  size. 

2.  Egg  of  Ascaris  lumbricoides. 

3.  Egg  of  Oxyuris  vermicularis,   pin  worm. 

4.  Egg  of  TiBnia  solium. 

5.  Proglottides  or  links  of  Taenia  solium. 

6.  Proglottides  of  Bothriocephalus   latus. 

Round  Worms  (Ascarides  Lumbricoides). — This  parasite  is 
found  in  the  small  gut ;  it  may  invade  the  stomach  or  may  pass  down- 
ward into  the  rectum.  Cases  are  recorded  (Borger)  in  which  it  has 
passed  into  the  bile-duct  and  caused  abscess  of  the  liver.  There  may 
be  only  one  or  many  of  these  worms  in  the  gut.  Leuckart  states  that 
they  may  form  large  masses  in  the  gut,  and  thus  cause  intestinal 
obstruction.  They  have  been  known  to  perforate  the  gut  and  cause 
peritonitis.  The  eggs  are  introduced  into  the  gut  through  the  medium 
of  drinking-water,  fruit,  and  vegetables.  Epstein  cultivated  the  eggs 
outside  of  the  body  and  then  introduced  them  into  the  gut,  where  they 
developed.     The  male  worm  is  250  mm.  long,  the  female  being  longer. 

Symptoms. — The  symptoms  caused  when  these  parasites  have  once 
gained  access  to  the  body  are  not  characteristic,  I  have  seen  the 
worms  passed  or  vomited  by  children  apparently  in  normal  condition. 

Treatment. — The  treatment  consists  in  placing  the  patient  on  a 
milk  diet.  After  a  few  days  the  following  powder  is  administered 
two  or  three  times  daily : 


INTESTINAL    PAEASITES.  557 

Calomel, 

Santonin aa  gr.  ^  (0.016). 

Santonin  is  sometimes  administered  in  the  form  of  pastiles,  but  is  not 
more  satisfactory  than  the  above  preparation. 

Oxyuris  Vermicularis  (Pin  Worm;  Thread  Worm). — Brass 
showed  that  the  habitat  of  these  worms  is  the  small  intestine,  whence 
they  pass  into  the  csecum.  The  female  worm  lays  its  ova  in  the  folds 
of  the  gut.  They  may  pass  into  the  stomach  and  thence  into  the 
mouth,  but  more  frequently  pass  out  of  the  anus  into  the  vagina  or 
into  the  prepuce  and  urethra.  They  exist  in  enormous  numbers  in 
the  gut,  are  exceedingly  small,  and  have  the  appearance  of  fibres  of 
cotton  fabric.  They  can  be  seen  by  spreading  the  nates  apart. 
They  are  then  found  in  the  anus,  or  in  female  children  in  the  four- 
chette.  The  principal  symptom  is  intolerable  pruritus,  so  intense  as 
to  deprive  the  children  of  sleep.  This  worm  is  found  only  in  the 
human  subject.  It  is  conveyed  from  person  to  person  through  un- 
cleanliness.  The  larvae  adhere  to  the  fingers,  and  thence  are  intro- 
duced into  food-stuffs. 

Treatment. — It  is  a  very  difficult  task  to  dislodge  these  worms; 
injections  by  the  rectum  cannot  reach  those  higher  in  the  intestine. 
The  plan  which  I  have  followed,  and  which  gives  relief,  is  to  give 
daily  enemata  of  quassia  wood  before  bedtime: 

Quassia  wood  (ground) 5J  (31.0). 

AquJB  dest Oj  (500.0). 

Make  an  infusion  and  strain. 

I  have  in  addition  utilized  the  prescription  of  santonin  and  calomel 
given  above  for  the  round  worms. 

Schmitz  recommends  the  administration  of  naphthalin,  grains  j  to 
iij  (0.06  to  0.18),  t.  i.  d.,  for  a  week,  after  which  it  is  discontinued 
for  a  few  days,  and  then  given  again. 

Tapeworm  {Tcenia). — Taenia  are  quite  common  in  children,  and 
have  been  found  in  the  newborn  infant  (Miiller  and  Armor).  ISTu- 
merous  cases  have  been  recorded  of  the  presence  of  these  worms  in 
infants  from  the  third  to  the  twelfth  month.  They  are  most  fre- 
quently found  between  the  first  and  the  third  year.  The  varieties 
most  commonly  found  in  children  are :  Taenia  solium.  Taenia  medio- 
canellata,  Taenia  elliptica,  Bothriocephalus  latus. 

Sources  and  Varieties. — Tcenia  Elliptica. — The  lice  of  the  house- 
dog and  cat  are  introduced  by  the  fingers  of  the  children  into  their 
mouths,  and  thus  gain  access  to  the  gut.  There  the  larvae  of  the 
tapeworm  which  they  contain  develop. 

Taenia  Solium. — The  larvae  of  this  worm  are  found  in  badly 
cooked  pork  or  beef. 

Tcenia  Medio canellata. — The  larvae  of  this  worm  are  found  in 


558  INTESTINAL    PABASITES. 

beef.  Bothriocepiialiis  latus  is  introduced  by  the  ingestion  of  infected 
fish-food. 

The  larva3  of  tapeworm  may  exist  in  the  flesh  of  the  hare,  pigeon, 
pheasant,  chicken,  goose,  or  duck.  Ice,  if  made  from  infected  water, 
may  be  a  means  of  introducing  the  larvae  in  the  body.  It  is  thus 
not  necessarily  the  meat-eating  children  who  run  the  danger  of  swal- 
lowing the  larvse  of  tapeworm ;  milk  if  diluted  with  infected  water 
may  contain  them. 

Symptoms. — Tapeworms  may  exist  for  months  or  years  in  the 
body  of  a  child  without  causing  untoward  symptoms.  As  many  as 
three  varieties  of  the  worm  have  been  found  in  the  same  child.  The 
symptoms  are  not  characteristic.  The  passage  in  the  movements  of 
the  links  of  the  tsenia  is  the  only  positive  evidence  of  their  presence. 

Treatment. — The  only  successful  treatment  for  the  expulsion  of 
the  tapeworm  is  that  which  consists  in  the  administration  of  filix 
mas  in  some  form.  It  should  be  freshly  prepared  and  given  in 
liberal  doses:  Ext.  seth.  filix  mas,  TlXxxx  (2.0)  to  5j  or  5ij  (4.0  or 
8.0),  is  made  into  an  emulsion  with  gum  tragacanth,  and  mixed  with 
equal  parts  of  castor  oil.  The  administration  of  this  mixture  is  pre- 
ceded by  a  day  or  more  of  milk  diet.  The  child  is  then  given  from 
half  a  drachm  to  a  drachm  (2.0  to  4.0)  of  the  filix  mas  with  castor 
oil  in  divided  doses.  The  recumbent  posture  is  maintained  in  case 
nausea  should  be  experienced.  The  movements  containing  the  worm 
are  carefully  washed  through  a  sieve,  and  the  smallest  part  of  the 
worm  sought  for  in  order  to  see  if  the  head  has  come  away. 

The  patient  should  be  given  a  drawing  of  the  comparative  size  of 
the  head  and  links  of  the  worm,  in  order  that  the  head  may  not  be 
lost,  or  the  physician  may  seek  it  himself. 

Uncinariasis  or  Hook-worm  Disease. — This  disease  is  widely 
prevalent  in  the  South,  where  some  two  million  men,  women  and  chil- 
dren are  said  to  be  affected.     The  children  are  the  principal  victims. 

Etiology. — This  disease  was  brought  to  America  by  the  negro, 
whose  habits  lead  to  infection  of  the  soil  and  spread  of  the  disease  to 
the  white  man.  The  hook-worm  was  known  to  the  Egyptians.  In, 
Europe  it  was  discovered  in  the  badger  by  Goeze  in  1782  and  was 
named  by  Froelich  hook-worm.  It  was  long  recognized  in  the  South, 
but  Stiles  isolated  a  distinct  American  species  of  Anchylostoma  duo- 
denale,  the  European  worm,  in  1902.    . 

Since  then  the  literature  is  rich  in  clinical  descriptions  of  the 
affection  now  called  hook-worm  disease.  Adams  described  some  cases 
in  children.  The  hook-worm,  or  Uncinaria  americana,  is  so  called 
because  in  the  American  variety  the  head  turns  backward,  forming 
a  hook,  while  in  the  European  variety  the  Anchylostoma  duodenale, 
the  mouth  contains  four  hood-like  processes  by  means  of  which  the 


INTESTINAL    PABASITES. 


559 


parasite  fastens  itself  to  tlie  intestine  (Fig.  114).  The  worm  is  half 
an  inch  long,  its  habitat  is  the  intestine,  it  sucks  blood  and  at  the  same 
time  injects  into  the  circulation  a  toxin.  The  parasite  produces  eggs 
which  may  be  hatched  outside  of  the  intestine  in  about  24  hours,  pro- 
ducing larvae.  The  infection  is  carried  by  the  hands  and  drinking 
water.  It  is  found  in  the  soil  of  the  sandy  southern  districts.  It 
may  enter  the  body,  as  established  by  Loos,  through  the  skin.  Enter- 
ing the  hair-follicles,  it  gains  admission  into  the  circulation,  then  into 
the  lungs  and  cesophagus  and  into  the  stomach. 

Symptoms. — The  symptoms  consist  in  a  progressive  ansemia;  the 
hemoglobin  in  Adams's  case  was  reduced  to  20  per  cent.  The  skin 
is  dark,  waxy  and  hydrsemic,  the  face  is  bloated,  the  abdomen  pro- 

FiG.  114. 


American  hook-worm  larvae,  eggs.      Small  figure  shows  actual  size. 


tuberant  and  emaciation  results,  with  a  tendency  to  skin  ulceration. 
The  tongue  is  brown  and  spotted  and  the  mucous  membranes  pale. 
The  temperature  may  be  subnormal  or  there  is  occasional  fever.  The 
muscular  weakness  is  extreme  and  mental  apathy  and  stupidity  are 
characteristic.  There  is  headache,  dizziness,  epigastric  pain  and  a 
craving  for  peculiar  articles  of  diet.  I^early  all  of  the  victims  of  the 
affection  are  dirt-eaters.  There  may  be  constipation  or  diarrhoea. 
The  blood  shows  diminution  of  white  blood-cells  and  eosinophilia. 

Diagnosis. — The  diagnosis  is  made  from  an  examination  of  the 
fseces  in  which  the  eggs  of  the  parasite  are  found.  Stiles  describes 
the  eggs,  which  are  60  to  70  /^  in  length  and  41  to  46  /x  in  width.  The 
larvse  may  be  developed  from  them  artificially.  The  disease  may 
last  for  years  if  not  eradicated  by  treatment.  ISTeglected  cases  cannot 
be  cured. 

Treatment. — Treatment  is  the  administration  of  thymol  suggested 
by  Bozzolo.  There  must  be  an  abstinence  during  treatment  from 
alcohol  or  fatty  substances  which  dissolve  the  thymol.  Adams  gave 
his  patient,  a  boy  of  twelve,  30  grains,  in  doses  of  10  grains  every 


560  DISEASES    OF    TEE    LIVEB. 

hour  and  a  half,  followed  bv  Epsom  salts.  After  a  time  the  faeces 
are  examined.  If  the  ova  are  still  present,  the  treatment  is  repeated. 
Good  food  and  tonics  aid  restitution. 

DISEASES   OF    THE   LIVER. 

Anatomical. — The  weight  of  the  liver  in  infants  and  children  is 
from  one-twentieth  to  one-thirtieth  of  the  body  weight;  in  the  adult 
it  is  one-fortieth. 

Weight. — Birch-Hirschfeld  gives  the  following  weights  of  the 
liver : 

Birth 127  5  years 480 

6  montlis 197  10  Tears 830 

1  year 312  Adult 1627 

2  years 346 

Examination. — The  liver  is  examined  with  the  patient  in  the 
recumbent  or  semirecumbent  posture.  The  physician  may  palpate 
for  the  liver  or  mark  out  the  organ  more  accurately  by  percussion. 
In  marking  out  the  organ,  the  upper  limit,  the  lower  edge,  and  the 
area  of  superficial  dulness  are  determined.  Perfect  accuracy  by  deep 
percussion  is  not  feasible,  because  in  order  to  obtain  absolute  dulness 
some  force  must  be  used,  and  vibratory  echoes  of  other  neighboring 
organs — ^the  lungs  and  intestines — are  thus  caused.  In  all  cases  it 
it  well  to  determine  the  upper  limit  of  dulness  at  a  point  where  the 
liver  comes  in  contact  with  the  chest-wall. 

The  lower  border  of  the  liver  is  determined  by  palpation  and  per- 
cussion. The  lower  border  projects  normally  in  infants  and  children 
below  the  border  of  the  ribs.  In  the  right  mamillary  line  this  pro- 
jection may  vary  from  1  to  2.5  cm.  At  the  xiphoid  appendix  the 
liver  may  project  to  the  extent  of  2  to  6  cm.  and  still  be  within  the 
normal  limits.  These  conditions  may  exist  up  to  the  tenth  year. 
The  exact  age  at  which  the  liver  assumes  the  adult  dimensions  has 
not  been  determined.  In  some  adults,  however,  the  projection  below 
the  border  of  the  ribs  is  the  same  as  in  children.  Since  the  size  of 
the  liver  varies,  caution  should  be  exercised  in  pronouncing  the  organ 
enlarged.  The  gut,  ascites,  and  tympanitic  distention  may  obscure 
the  lower  limit  of  the  liver  both  to  palpation  and  percussion. 

Palpation. — By  palpation,  the  location  of  the  lower  border  of  1he 
liver  may  be  determined,  and  whether  it  is  rounded  or  sharp,  also, 
if  the  liver  be  enlarged,  the  character  of  the  projecting  portion,  whether 
smooth  or  even.  In  infants  and  children  the  region  of  the  gall-bladder 
is  palpated,  but  it  is  difficult  to  determine  in  these  subjects  whether 
this  organ  is  enlarged  or  absent.  Henoch  and  Murchison  have  re- 
corded fatal  cases  of  increasing  and  persistent  icterus  in  which  there 
was  congenital  absence  of  the  gall-bladder. 


DISEASES    OF    THE    LIVER. 


561 


Percussion. — Percussion  should  be  performed  in  the  mid-line  from 
the  base  of  the  xiphoid  cartilage  downward,  in  the  right  mammillarj 
line  from  above  downward,  and  sometimes  in  the  mid-axillary  line. 
In  order  to  determine  accurately  the  superficial  dulness,  the  whole 
extent  of  the  dulness  should  be  measured.  This  is  rarely  necessary 
except  in  investigations  for  scientific  purposes.  In  cases  of  effusion 
into  the  pleural  cavity,  the  upper  limit  of  dulness  is  continuous  with 
the  dulness  or  flatness  of  the  fluid.  The  displacement  below  the 
border  of  the  ribs  only  can  then  be  determined.     In  rare  cases  of  sub- 

FiG.  115. 


Method  of  palpating  the  projection  of  the  liver  below  the  ribs. 

phrenic  abscess  there  is  an  extension  of  the  upper  limit  of  dulness  into 
the  limits  of  the  chest  cavity,  and  displacement  of  the  lower  border 
of  the  liver  downward.  StefFen  gives  the  following  measurements  of 
the  superficial  liver  dulness  in  the  median  and  mammillary  lines : 

Midline.  Mammillary  line. 

At  birth 3.5  cm.  2      cm. 

At  one  month 5       "  5        " 

At  six  month.s 4.5     "  4.5    " 

At  one  year 4.5    "  4        " 

At  two  years 5.2    "  5       " 

At  five  years  .    . 5       "  6.5    " 

At  ten  years 5       "  6       " 


These  measurements  also  vary  greatly,  especially  in  infants  under 
one  year  of  age. 

Tumors  and  Conditions  Simulating  Enlargement  or  Disease  of 
the  Liver. — The  following  tumors  and  conditions  simulate  enlarge- 
ment or  disease  of  the  liver:  normal  rotation  of  the  liver;  phantom 
tumor;  circumscribed  empyema,  or  pleuritic  effusion;  subphrenic 
abscess ;  circumscribed  peritoneal  effusion  between  the  liver  and  dia- 
phragm ;  tumors  or  cysts  of  the  right  kidney. 

Normal  Rotation  of  the  Liver.- — In  infants  below  two  years  of  age 
the  liver  may  have  a  lax  suspensory  ligament.     In  such  cases  the 

36 


5G2  DISEASES    OF    TEE    LIVER. 

liver  will  rotate  and  be  found  for  a  varying  distance  below  the  free 
border  of  the  ribs,  depending  mncb  on  the  amount  of  distention  of 
the  intestine.  When  the  latter  is  not  distended  the  liver  will  rise  up 
beneath  the  free  border  of  the  ribs. 

Phantom  Tumor. — Phantom  tumor  is  described  by  Murchison.  It 
is  a  soft  or  hard  epigastric  tumor,  which  may  project  downward  as 
far  as  the  umbilicus.  Whether  it  is  dull  with  a  tympanitic  note,  or 
tympanitic,  depends  on  the  amount  of  muscular  contraction.  There 
is  no  fluctuation  or  flatness.  The  tumor  is  present  when  the  patient 
is  standing  or  in  the  recumbent  position.  It  disappears  under  anaes- 
thesia. A  tumor  of  this  kind  should  not  be  punctured  until  it  has 
been  observed  under  anaesthesia,  since  there  is  danger  of  puncturing 
the  intestine  and  causing  peritonitis. 

Empyema. — In  simple  or  encapsulated  empyema  on  the  right  side, 
the  liver  is  displaced  downward.  The  upper  dulness  extends  into 
the  pleural  cavity;  the  lower  part  of  the  thorax  may  enlarge  to  such 
an  extent  as  to  press  the  ribs  apart  and  cause  fluctuation  between 
them.  There  will  be  dulness  or  flatness  in  front  or  behind  over  the 
lower  part  of  the  pleural  space,  and  perhaps  disappearance  of  the 
respiratory  murmur.  It  should  not  be  forgotten  that  there  is  always 
a  possibility  of  the  presence  of  subphrenic  abscess,  or  of  abscess  in 
the  upper  part  or  on  the  surface  of  the  liver,  bulging  into  the  pleural 
cavity.  In  that  case  there  will  not  only  be  bulging  of  the  lower  ribs^ 
but  also  a  continuation  of  dulness  for  a  variable  distance  upward. 
The  liver  may  be  enlarged  downward  or  not  at  all.  If  the  tumor  is 
beneath  the  diaphragm  and  displaces  the  liver  downward,  the  respira- 
tory murmur  may  be  heard  to  the  normal,  or  almost  normal,  limit, 
and  yet  dulness  due  to  the  upward  projection  of  the  tumor  may  be 
present. 

Kidney  Tumor. — Kidney  tumor  may  extend  from  behind,  beneath 
the  liver,  and  simulate  liver  tumor.  In  such  cases,  the  lumbar  flat- 
ness extending  below  the  border  of  the  ribs  will  be  a  guide. 

Enlargements  of  the  Liver. — Enlargements  of  the  liver  in  infancy 
and  childhood  present  much  the  same  physical  signs  as  in 'the  adult, 
but  there  are  some  states  which  are  peculiar  to  early  life. 

Anaemia  Infantum  Pseudoleukaemica  of  von  Jaksch. — Anaemia  in- 
fantum pseudoleukEcmiea  of  von  Jaksch  causes  great  enlargement  of 
the  liver  and  spleen.  The  lower  edge  of  the  liver  is  rounded;  the 
lymph-nodes  are  enlarged,  and  the  blood  presents  certain  features 
characteristic  of  this  anaemia. 

Simple  Rachitis. — Simple  rachitis  causes  slight  or  marked  enlarge- 
ment of  the  liver,  as  well  as  real  enlargement  of  the  spleen.  •  In  some 
cases,  the  liver  is  not  really  enlarged,  bnt  ma}"  be  disjDlaced  downward 


DISEASES    OF    THE    LIVEB.  563 

bj  the  deformity  of  the  thorax.  Simple  icterus  usually  causes  en- 
largement of  the  liver,  which  retrogrades  after  a  few  weeks. 

Still's  Rheumatoid  Arthritis. — In  Still's  rheumatoid  arthritis  there 
is  considerable  enlargement  of  the  liver. 

Congenital  Syphilis. — Congenital  syphilis  may  cause  slight  en- 
largement of  the  liver  which,  up  to  the  end  of  the  second  year,  is 
present  without  icterus.  The  liver  is  enlarged  in  cirrhosis  abscess, 
and  fatty  degeneration  of  the  organ.  It  is  greatly  enlarged  in  acute 
and  chronic  leukaemia. 

Jaundice  {Catarrhal  Icterus;  Catarrhal  Jaundice;  Infectious 
Icterus). — Simple  jaundice  is  a  common  disease  of  infancy  and  child- 
hood. In  its  simplest  form,  it  was  formerly  believed  to  be  due  to  an 
obstruction  of  the  common  bile-duct  with  mucus.  In  recent  years, 
the  French  clinicians  have  described  a  form  of  jaundice  which  they 
regarded  as  infectious.  The  first  cases  of  the  kind  were  published 
in  1881  by  Weiss,  Chauffard,  and  Landouzy,  in  France,  and  by  Weil, 
in  Germany.  There  is  at  present  a  tendency  to  regard  all  cases  of 
jaundice  in  infants  and  children,  not  due  to  mechanical  obstruction 
of  the  duct  or  disease  of  the  liver,  as  infectious  (Botkin,  Hennig^ 
Barthez,  Henoch,  and  others).  Thus  simple  icterus  would  be  re- 
garded as  a  mild  form  of  infectious  icterus.  This  view  has  recently 
been  elaborated  by  Kissel.  The  theory  that  errors  of  diet  cause  a 
catarrh  of  the  gut,  extending  into  the  duct  and  thus  obstructing  it, 
finds  little  support.  On  the  other  hand,  the  theory  of  the  infectious 
nature  of  even  the  mildest  cases  of  jaundice  is  supported  by  the  fact 
that  these  cases  occur  in  groups  and  epidemics. 

Morbid  Anatomy. — In  cases  of  fatal  icterus,  there  are  found 
atrophy  and  fatty  degeneration  of  the  liver  cells.  The  interstitial 
tissue  around  the  portal  vein  is  infiltrated  with  small  round  cells. 
There  is  parenchymatous  degeneration  of  the  kidney.  The  whole 
picture  resembles  that  of  acute  yellow  atrophy.  The  mild  cases  of 
icterus  have  not  yet  been  studied. 

Bacteriology. — The  bacteriology  of  the  various  forms  of  icterus 
remains  to  be  studied.  In  one  case  Jager  found  a  bacillus  of  the 
proteus  group  in  the  urine. 

Occurrence.^ — The  disease  may  appear  at  any  period  of  infancy 
and  childhood.     It  is  most  common  between  the  second  and  fifth  years. 

At  present,  all  primary  forms  of  jaundice  may  be  clinically  clas- 
sified as  follows  :  The  very  mild  forms  (catarrhal  icterus)  ;  the  severer 
forms ;  the  fatal  forms.  It  is  highly  probable  that  all  are  infectious 
in  origin.  The  secondary  forms  of  jaundice  are  not  considered  in 
this  section. 

Symptoms. — In  the  mildest  forms  there  are  no  symptoms  at  the 
onset.     In  some  mild  cases  there  are  vomiting,  constipation  or  symp- 


564  DISEASES    OF    THE    LIFEB. 

toms  of  intestinal  indigestion  and  fetor  of  the  breath,  and  the  tongue 
is  coated.  The  skin  assumes  a  saffron  hue  and  the  conjunctivse  are 
distinctly  yellow.  The  appetite  is  capricious ;  the  urine  is  brownish 
and  contains  bile-pigment.  The  movements  are  like  clay,  and  may 
have  a  bad  odor.  There  is  pruritus  of  the  surface.  The  child  may 
be  somewhat  depressed.  In  the  very  mild  forms  there  is  no  febrile 
movement.  In  the  majority  of  cases,  there  is  rapidity  of  pulse  and, 
in  some  cases,  irregularity.  In  the  severer  forms  the  symptoms  are 
more  marked.  The  vomiting  recurs  at  intervals,  the  intensity  of  the 
jaundice  is  much  the  same  as  in  the  mild  forms,  and  the  temperature 
may  in  the  course  of  the  disease  be  raised  a  degree  or  more.  The 
attack  may  be  ushered  in  by  a  chill.  There  is  some  prostration  and, 
in  a  few  cases,  diarrhoea.  The  fatal  cases,  which  were  first  described 
by  Weiss  and  the  French  school,  are  severer  forms  of  infection.  The 
symptoms  of  cholsemia  are  much  more  marked.  There  are  delirium, 
unconsciousness,  and  cerebral  symptoms.  The  pulse  is  greatly  in- 
creased and  the  respirations  are  irregular.  The  patients  die  in  an 
asthenic  state. 

The  liver  is  enlarged  in  even  the  mildest  forms.  In  a  recent 
series  of  20  cases  of  mild  icterus,  I  found  the  liver  enlarged  from 
four  to  seven  centimetres  below  the  border  of  the  ribs,  in  the  mam- 
millary  line.  The  spleen  was  enlarged  in  most  cases.  The  fact  that 
in  the  mildest  forms  there  is  enlargement  of  the  spleen  lends  support 
to  the  infectious  theory  of  the  disease.  In  the  majority  of  my  cases, 
the  liver  remained  enlarged  long  after  the  icterus  had  disappeared. 
Kissel  also  found  this  to  be  the  case.  In  some  cases,  three  months 
elapsed  before  the  liver  returned  to  the  normal  limits. 

Duration. — The  disease,  even  in  the  mild  form,  lasts  from  two  to 
three  weeks.  The  fatal  forms  may  run  their  course  much  more 
rapidly. 

Treatment. — The  treatment  of  icterus  is  very  simple.  An  initial 
dose  of  calomel  is  given  and  the  bowels  are  well  evacuated.  The 
patient  is  put  on  a  milk  diet,  and  is  given  a  daily  enema  of  water  at 
a  temperature  of  85°  F.  (29.4°  C).  On  every  second  day  a  small 
dose  of  calomel,  grain  i  (0.03),  is  given  to  aid  the  enemata.  Fresh 
air  and  daily  alkaline  baths  are  beneficial.  Alkaline  baths  are  made 
by  adding  a  few  tablespoonfuls  of  sodium  carbonate  and  an  equal 
quantity  of  salt  to  the  water. 

Congenital  Obstruction  of  the  Bile-ducts. — Etiology. — The  etiol- 
ogy of  this  affection  is  obscure.  Some  TO  cases  of  this  condition  were 
recently  collected  by  ]\rorse  from  the  literature.  The  infants  may  be 
apparently  normal  at  1)irth. 

Symptoms. — liilcnsc  jaundice  is  the  first  symptom  noticed  at  birth, 
or  oji  lh(;  second   1o  1lic  foui-lli  day  after  birth.      Meconium  is  first 


DISEASES    OF    THE    LIVEB.  565 

passed  by  the  infant,  and  then  the  stools  are  clay  colored.  The  urine 
contains  biliary  coloring-matter.  The  liver  is  enlarged,  as  is  also 
the  spleen.  Hemorrhages  from  the  stomach  and  intestine  and  into 
the  skin  occur  in  tirde.  Death  occurs  early,  or  in  from  three  to  eight 
months.  In  one  of  my  cases  three  months  of  age,  laparotomy  showed 
the  gall-bladder  to  be  empty  and  shrunken.  The  liver  was  enlarged. 
There  was  an  absence  of  the  ducts  leading  to  the  gall-bladder.  The 
stools  were  formed,  white  like  curd  of  milk,  stained  only  slightly  as 
the  tissues  with  bile.     There  were  extensive  subcutaneous  hemorrhages. 

Morbid  Anatomy. — Some  portion  of  the  bile-ducts  may  be  oblit- 
erated and  replaced  by  connective  tissue.  In  other  cases  the  walls 
of  the  ducts  are  simply  swollen.  The  liver  is  enlarged  and  the  seat 
of  cirrhotic  changes. 

Cirrhosis  of  the  Liver. — This  disease  is  rare  in  infancy  and 
childhood.  Of  62  cases  collected  from  the  literature  by  v.  Kahlden, 
5  occurred  in  the  newborn,  12  in  the  first  two  years  of  life,  and  28 
from  the  ninth  to  the  thirteenth  year.  It  is  more  prevalent  in  the 
male  sex.  Of  those  cases  in  which  the  size  of  the  liver  was  recorded 
19  were  atrophic,  15  hypertrophic,  and  6  normal  in  size. 

Etiology. — Demme  has  published  2  cases  in  children  addicted  to 
the  use  of  alcohol.  The  influence  of  heart  disease  and  the  infectious 
diseases,  such  as  scarlet  fever  and  measles,  in  causing  cirrhosis  of  the 
liver  is  not  as  yet  understood.  Cirrhosis  of  the  liver  occurs  in  forms 
of  peritoneal  tuberculosis  and  in  syphilis. 

Morbid  Anatomy. — The  morbid  anatomy  of  the  affection  is  the 
same  as  in  the  adult. 

Symptoms. — The  symptoms,  which  are  the  same  as  in  the  adult, 
include  enlargement  of  the  liver  and  spleen,  icterus,  and  ascites.  The 
icterus  is,  as  in  the  adult,  constant. 

The  liver  is  not  always  enlarged,  and  in  the  cases  in  which  it  is 
of  normal  size  the  difficulties  of  diagTiosis  are  increased.  The  spleen 
is  most  constantly  enlarged. 

The  recorded  cases  of  cirrhosis  following  or  complicating  the 
exanthemata  and  diphtheria  gave  no  previous  symptoms. 

Fatty  Degeneration  of  the  Liver. — Fatty  degeneration  of  the 
liver,  with  or  without  enlargement  of  the  organ,  occurs  in  forms  of 
subacute  and  chronic  constitutional  dyscrasia.  I  have  seen  this  dis- 
ease in  infants  Avho  died  with  tuberculosis,  chronic  or  subacute  intes- 
tinal diarrhoea,  rachitis,  Henoch's  purpura,  or  acute  leukaemia.  I 
have  also  seen  it  in  cases  of  phosphorus-poisoning.  The  symptoms 
and  signs  do  not  differ  from  those  seen  in  the  adult.  The  diagnosis 
can  hardly  be  made  during  life. 

Syphilis  of  the  Liver. — Enlargement  of  the  liver  is  common  in 
syphilis  of  infants  and  children.     The  spleen  may  also  be  enlarged. 


566  DISEASES    OF    TEE    LIVEE. 

There  may  be  icterus.  There  may  be  other  symptoms  of  syphilis, 
but  none  which  can  be  traced  to  enlargement  of  the  liver. 

There  are  four  histological  forms  of  this  variety  of  hepatic  en- 
largement : 

a.  The  form  in  which  gummata  are  found  in  the  liver.  This  is 
rare.  I  saw  a  case  in  an  infant  sixteen  months  of  age  in  which  there 
were  also  gummata  of  the  cranial  and  the  long  bones. 

h.  The  diffusely  cirrhotic  liver.  In  this  form  the  connective 
tissue  is  quite  evenly  distributed  throughout  the  liver. 

c.  The  lobulated  liver,  in  which  the  connective  tissue  divides  the 
organ  into  sections.     I  have  seen  a  case  in  a  girl  eight  years  of  age. 

d.  The  so-called  miliary  syphilis  of  the  liver,  in  which  the  organ 
is  strewn  with  miliar}^  collections  of  round  cells  closely  resembling 
miliary  tubercle.  The  nodules  are  situated  in  the  interstitial  con- 
nective tissue.     They  rapidly  undergo  fatty  degeneration. 

Clinically  the  cases  which  I  have  met  were  mostly  those  in  which 
the  liver,  hard  and  nodular,  could  be  felt  below  the  border  of  the 
ribs.  In  one  case  there  was  a  history  of  syphilitic  accidents,  in 
another  old  cicatrices  existed  on  the  lips  and  face.  In  a  third  case 
the  patient  had'  Hutchinson  teeth;  the  liver  and  spleen  were  both 
enlarged  and  nodular. 

Abscess  of  the  Liver  (Suppurative  Hepatitis). — Etiology. — This 
disease  occurs  in  the  newborn  as  a  form  of  sepsis.  Otherwise  its 
etiology  in  infancy  and  childhood  is  identical  with  that  in  the  adult. 
It  may  follow  a  traumatism  or  complicate  appendicitis  (septic),  it 
may  occur  in  peritonitis  with  pyelophlebitis.  or  it  may  follow  the 
infectious  diseases,  or  dysentery.  In  the  literature  rare  cases  are 
described,  in  which  Ascarides  lumbricoides  have  caused  abscess  of 
the  liver  in  children,  by  migrating  into  the  gall-bladder  through  the 
common  duct. 

The  occurrence  of  this  disease,  though  not  rare  in  tropical  coun- 
tries, is  less  frequent  in  districts  in  which  dysentery  is  not  endemic. 
It  may  occur  as  early  as  the  fifth  month  of  infancy  (Oliveira).  The 
left  lobe  of  the  liver  is  most  frequently  involved.  The  Amoeba  coli 
is  not  always  the  cause,  being  an  etiological  factor  in  20  per  cent,  of 
the  cases. 

Symptoms. — The  symptoms  in  these  cases  are  first  those  of  dysen- 
tery; then,  after  improvement  sets  in,  the  symptoms  of  abscess,  with 
fever,  swelling  of  the  abdomen,  and  enlargement  of  the  liver  upon 
palpation  appear.  The  liver  may  enlarge  as  much  as  10  cm.  below 
the  tip  of  the  ensiform  cartilage. 

Course. — The  abscess  may  perforate  into  the  intestine,  pleura,  or 
peritoneum.  If  it  perforate  into  the  intestine  recovery  results.  Any 
other  termination  is  disastrous. 


DISEASES    OF    THE    PEBITONEUM.  567 

Treatment. — The  treatment  of  abscess  of  the  liver  in  children  is 
much  the  same  as  in  the  adult.  If  operated  early  the  prognosis 
is  good. 

Acute  Yellow  Atrophy  of  the  Liver. — The  disease  is  extremely 
rare  in  infancy  and  childhood.  Lanz  published  a  case  in  a  boy  four 
years  of  age.  In  that  there  was  no  splenic  tumor  or  hemorrhages,  it 
differed  from  the  picture  in  adult  cases.  The  cases  in  the  literature 
are  as  follows :  Pollitzer,  infant,  one  month  of  age ;  Senator,  infant, 
eight  months;  Mann,  infant,  ten  months;  Greves,  infant,  twenty 
months ;  Widerhofer,  child,  one  and  three-fourths  years ;  Eehn,  child, 
two  and  one-half  years;  Loschner,  child,  three  and  one-half  years; 
Mettenhemier,  child,  four  years;  West,  child,  six  years;  Merkel, 
child,  six  and  one-half  years ;  Rosenheim,  child,  ten  years ;  Steiner, 
child,  ten  years ;  Folwarczny,  child,  fourteen  years. 

I  have  seen  only  one  case  of  atrophic  liver.  The  patient,  a  boy 
of  eleven  years  of  age,  with  very  small  kidneys,  had  nephritis  which 
had  appeared  six  years  after  an  attack  of  scarlet  fever.  The  liver 
dulness  became  gradually  smaller  from  the  time  of  admission  to  the 
hospital  until  death.  At  autopsy,  the  liver  was  found  to  have  one- 
half  the  normal  weight  and  to  be  the  seat  of  marked  parenchymatous 
degeneration. 

Tumors  of  the  Liver.- — Tumors  of  the  liver  in  infancy  and  child- 
hood may  be  benign  or  malignant. 

The  benign  are  cavernous  tumors  or  cystic  degenerations  of  the 
liver. 

The  malignant  tumors  are  the  carcinomata  or  adeno-carcinomata 
and  more  rarely  sarcomata.  Steffen  collected  39  cases  of  primary 
malignant  growths  of  the  liver  occurring  mostly  in  the  newborn. 

Stoos  observed  an  adeno-carcinoma  in  a  child  five  years  of  age. 

Parasites  of  the  Liver. — These  are  exceedingly  rare  and  are 
classified  by  Stoos  as  Distoma  hepaticum,  Ascarides,  Echinococcus, 
Cystocerci,  and  Pantastomum  denticulatum. 

Biliary  Calculi. — Still  has  collected  8  cases  ranging  from  2  to  14 
years  of  age.  I  have  had  two  cases  in  older  children.  Lillienthal 
has  operated  in  several  cases,  one  a  boy  of  five  years  of  age. 

The  symptoms  are  similar  to  those  in  the  adult.  Still's  cases 
were  mostly  in  the  newborn,  the  main  symptom  being  intense  per- 
sistent icterus.  On  autojDsy  multiple  calculi  were  found  in  the 
biliary  ducts. 

DISEASES    OF    THE    PERITONEUM. 

Ascites. — Ascites  is  a  serous  effusion  into  the  peritoneal  sac,  and, 
as  in  the  adult  subject,  it  is  generally  secondary  either  to  some  disease 


568  DISEASES    OF    THE    PEBITONEUM. 

of  the  peritonenm,  siicli  as  tuberculosis,  or  chronic  disease  of  the 
heart,  liver,  or  kidneys.  It  may  also  be  due  to  some  obstruction  of 
the  portal  circulation,  caused  by  enlarged  glands  or  tumors  of  the 
peritoneum.  Ordinary  ascites  has  the  same  characteristics  in  the 
infant  and  child  as  in  the  adult,  and  is  recognized  by  the  same  phys- 
ical signs.  It  is  therefore  superfluous  to  go  into  details  in  this  place 
as  to  the  physical  characteristics  of  the  fluid  accumulation  in  the  peri- 
toneal cavity  of  infants  or  children. 

Some  rare  forms  of  ascites  may  be  congenital.  In  diagnosing 
ascites  in  infants  and  children,  v^e  must  be  careful  not  to  confound 
it  with  local  accumulations  of  fluid  due  to  cysts  or  tumors  in  the  peri- 
toneal cavity.  Cysts,  or  cystic  tumors,  have  local  circumscribed 
physical  characteristics,  and  with  care  they  cannot  be  mistaken  for 
ascites.  There  is  a  form  of  ascites  which  occurs  rarely  in  children, 
and  of  which  I  have  seen  one  example  in  a  boy  six  years  of  age.  It 
is  called  chylous  ascites,  and  is  marked  by  its  chronicity  and  the 
milky  or  fatty  nature  of  the  exudate.  It  is  more  frequent  in  adults ; 
but  when  present  in  infants  or  children,  it  is  found  between  the  ages 
of  seven  and  ten  years.  In  one  case  recorded  by  Wicklen,  the  accu- 
mulation followed  an  attack  of  pertussis  in  an  infant  six  months  of 
age.  In  a  case  recently  reported  by  Kerr  the  ascites  disappeared 
after  abdominal  tap.     There  was  a  history  of  syphilis. 

The  etiology  of  chylous  ascites  is  obscure,  although  in  some  cases 
tuberculosis  of  the  peritoneum  has  been  found  postmortem.  It  has 
followed  traumatism,  eruptive  fevers,  or  an  infection  with  filaria. 
The  symptoms  are  those  of  ascites,  and  it  is  not  until  the  withdrawal 
of  the  fluid  that  the  true  nature  of  the  affection  is  discovered.  The 
fluid  withdrawn  has  a  milky,  opalescent  appearance,  and  is  of  two 
forms,  in  one  of  which  there  is  a  fine  emulsion  of  fat-globules  with 
red  and  white  blood-cells ;  the  other  form  contains  no  such  element, 
but  is  chylous  in  color.  At  autopsy  various  lesions  have  been  found, 
as  stated,  including  tuberculosis,  syphilis  of  the  liver,  cirrhosis  of  the 
liver,  an  enlarged  spleen,  with  lesions  of  the  thoracic  duct.  In  some 
cases  there  has  been  tuberculosis  of  the  thoracic  duct,  or  this  combined 
with  tuberculous  disease  of  the  lymph-nodes,  with  apparent  obstruc- 
tion of  the  lymph-vessels. 

Treatment. — The  treatment  of  ascites  in  children  is  carried  out 
along  the  same  lines  as  in  the  adult  patient. 

Acute  Peritonitis. — Acute  peritonitis  may  be  general  or  local, 
and  is  due  to  an  infection  of  the  peritoneum. 

Etiology. — According  to  Tavel,  Lanz,  and  Treves,  the  disease  is 
caused  by  various  bacteria,  such  as  streptococci,  staphylococci,  pneu- 
mococci,  or  coli  bacteria,  but  the  most  active  role,  even  in  the  traumatic 
and  perforative  forms,  is  played  by  the  Bacterium  coli  communis. 


DISEASES    OF    THE    PEEITONEUM.  569 

Krogius  examined  40  cases  of  perforative  peritonitis  following  appen- 
dicitis, in  20  of  which  he  found  two  or  three  species  of  bacteria ;  in 
only  7  cases  did  he  find  Bacterium  coli  alone.  The  species  found 
were  generally  coli  bacteria  in  combination  with  diplococci,  pneumo- 
cocci,  Diplococcus  intestinalis,  streptococci,  coli  gracilis.  The  re- 
maining cases  contained  the  Streptococcus  pyogenes,  pyocyaneus,  and 
Proteus  vulgaris.  The  coli,  however,  was  the  most  frequent  micro- 
organism found.  It  is  to  be  remarked  that  in  21  cases  the  Diplo- 
coccus pneumoniae  was  found  combined  with  the  Bacterium  coli. 
This  form  must  not  be  confounded  with  the  cases  in  which  the  pneu- 
mococcus  is  found  as  the  causative  agent  of  peritonitis,  especially  in 
children  (JSTetter,  Sevestre,  and  others). 

"We  may  have:  (1)  Acute  tuberculous  peritonitis,  (2)  Perfora- 
tive peritonitis,  due  to  traumatism  or  some  pathological  perforation 
of  the  viscera  or  the  serous  coat  of  the  intestine  as  a  result  of  tuber- 
culosis, typhoid  fever,  dysentery,  perforating  ulcer  of  the  stomach  or 
duodenum,  abscess  of  the  liver,  cyst  of  the  liver,  kidney,  or  spleen, 
rupture  of  the  gall-bladder,  strangulated  hernia,  intestinal  intussus- 
ception, appendicitis,  perforating  lumbricoides — all  these  can  be 
accompanied  by  the  escape  of  gas,  faecal  matter,  bile,  or  blood  into 
the  peritoneal  cavity.  (3)  Peritonitis  may  take  place  by  extension, 
as  is  observed  in  cases  where  inflammation  extends  from  a  viscus 
without  perforations.  (4)  Peritonitis  may  occur  as  the  result  of 
traumatism,  as  a  blow  or  fall  or  an  operation.  (5)  Pneumococci 
may  cause  an  acute  primary  peritonitis,  or  may  give  rise  to  the  affec- 
tion by  extension  from  the  pleura  or  lung.  (6)  There  is  a  gonor- 
rhoeal  form  of  peritonitis.  (7)  Peritonitis  may  occur  in  the  foetus 
or  in  the  newborn.  The  latter  has  been  described  by  Billard  as  fol- 
lowing intra-uterine  infection,  as  a  result  of  maternal  disease;  or  in 
the  newborn  peritonitis  may  be  caused  by  streptococcal  infection  of 
the  umbilicus,  and  extension  from  this  point  to  the  peritoneum. 

Symptoms. — The  symptoms  of  acute  peritonitis  at  the  onset  may 
be  insidious.  Such  forms  occur  in  cachectic,  marantic  infants,  or 
children;  or  the  onset  may  be  acute  and  sudden,  as  in  the  primary 
form. 

Pain  may  be  localized  either  in  the  iliac  fossa  or  around  the  umbil- 
icus, spreading  thence  over  the  whole  abdomen.  The  child  lies  quietly 
on  the  back,  with  superficial  respiratory  movement.  There  is,  as  in 
the  adult  subject,  meteorism  or  tympanites.  There  is  vomiting,  first 
of  the  contents  of  the  stomach,  then  the  vomitus  becomes  green  or 
biliary.  It  may  subside  after  two  or  three  days.  There  may  be  a 
diarrhoea,  but  in  most  cases  there  is  constipation  as  obstinate  as  in 
intestinal  obstruction.  The  tongue  is  moist,  then  dry;  the  buccal 
mucous  membrane  may  be  covered  with  sprue ;  the  urine  may  be  sup- 


570  DISEASES    OF    THE    PEEITONEUM. 

pressed,  and,  as  in  the  adult,  there  may  be  facies.  The  pulse  ranges 
from  120  to  150,  small  and  thready.  The  fever  varies  in  extent, 
depending  very  much  on  the  acuity  of  the  infection.  In  perforative 
peritonitis  there  will  be  a  sharp  rise  of  temperature. 

Physical  Signs. — The  physical  signs  are  much  the  same  as  are 
found  in  the  adult.  There  is  tympanites,  the  abdomen  is  distended, 
there  is  a  disappearance  of  the  liver  dulness.  In  localized  peritonitis 
there  is  local  pain ;  in  general  peritonitis  the  pain  is  general.  If  the 
peritonitis  becomes  general,  there  is,  as  a  rule,  an  accumulation  of 
fluid  in  the  peritoneal  cavity,  and  this  may  be  made  out  by  dulness 
in  the  flanks.  As  a  rule,  an  examination  of  the  blood  will  reveal  an 
increased  number  of  leucocytes  or  so-called  leucocytosis,  especially  in 
the  perforative  forms.  This  latter  sign  is  not  of  much  value  unless 
a  previous  leucocyte-count  has  been  made  or  the  case  has  been  under 
constant  observation,  such  as  in  forms  of  perforation  occurring  in 
typhoid  fever,  for  even  in  these  cases  the  increase  in  the  number  of 
the  leucocytes  is  only  comparative.  Thus  the  leucocyte-count  in  the 
course  of  typhoid  fever  may  be  6000  to  8000 ;  whereas  after  perfora- 
tion the  leucocytes  may  not  increase  beyond  10,000  to  12,000.  In 
other  words,  they  may  simply  reach  the  normal  limit. 

Course  and  Termination.- — Acute  peritonitis,  as  in  the  adult,  may 
remain  localized  or  may  spread  and  become  general.  In  the  latter 
case  the  prognosis  is  very  grave.  If  local  the  exudate  may  become 
encysted,  or,  if  general  and  left  to  itself,  may  result  fatally,  or  the 
exudate  in  the  peritoneal  cavity  may  rupture  in  the  vicinity  of  the 
umbilicus  or  through  the  vagina  or  rectum.  Foudroyant  cases  last 
two  or  three  days  and  result  in  death.  This  is  especially  so  of  the 
newborn. 

Complications. — Among  the  complications  of  acute  peritonitis, 
either  general  or  localized,  are  pleurisy,  pericarditis,  meningitis, 
pyaemia. 

Prognosis. — As  stated,  the  general  perforative  forms  present  the 
gravest  prognosis.     Peritonitis  of  the  newborn  is  fatal. 

Differential  Diagnosis. — Peritonitis,  acute,  localized,  or  diffuse,  must 
be  differentiated  from  typhoid  fever.  In  the  latter  disease  there  is 
sometimes  a  severe  inflammation  in  the  vicinity  of  the  vermiform 
appendix,  and  in  such  cases  we  should  be  very  careful  that  a  perfora- 
tion has  not  escaped  our  notice. 

Colprostasis,  or  intestinal  invagination,  and  gastro-enteric  infec- 
tion may  be  mistaken  for  appendicitis,  especially  in  young  children, 
if  the  meteorism  is  great. 

Gonococcal  Peritonitis.- — Gonococcal  peritonitis  results  from  an 
infection  of  the  peritoneal  cavity  by  the  Gonococcus  of  Neisser. 
Comby  records  7  cases  of  gonococcal  peritonitis.     Hunner  and  Harris 


DISEASES    OF    THE    PEBITONEUM.  571 

record  7  cases.     I  have  seen  2  cases.     The  infection  takes  place  by 
way  of  the  nterus  and  Fallopian  tubes  in  the  majority  of  cases. 

Etiology. — The  gonococcus  is  the  etiological  factor  in  these  cases, 
and  the  majority  of  recorded  cases  in  children  have  occurred  in  young 
infants  and  children  suffering  from  vulvovaginitis  of  a  gonorrhoeal 
nature.  In  my  tvsi'o  cases  this  was  the  etiological  factor.  The  symp- 
toms are  sudden  pain,  vomiting,  fever ;  or  in  other  cases  there  results 
in  the  course  of  the  vaginitis  severe  pelvic  pain.  In  some  cases  the 
pain  and  fever  are  of  short  duration,  and  it  must  be  surmised  in  these 
cases  that  the  inflammation  remains  well  localized  to  the  pelvis.  I 
have  seen  quite  a  numiber  of  these  cases  complicating  vaginitis  in 
young  girls. 

~  The  French  have  given  the  name  of  peritonism  to  these  cases, 
thereby  wishing  to  indicate  their  benign  nature.  The  symptoms  are 
so  slight  that  one  can  scarcely  believe  that  inflammatory  reaction  is 
present.  Baginsky  has  published  a  case  of  general  peritonitis  resulting 
from  gonorrhoea  of  the  tubes,  with  an  abscess-formation  in  Douglas's 
pouch.  The  gonococcus  of  this  form  of  peritonitis  may  be  associated 
with  other  bacteria,  such  as  the  staphylococcus.  There  are  several 
forms  of  gonorrhoeal  peritonitis :  the  general  acute  form,  ending  in 
death;  the  benign  pelvic  form,  with  subumbilical  pain,  and  a  third 
form  occurring  as  a  pelvioperitonitis  with  adhesions  and  salpingitis. 
Diagnosis  must  be  made  from  appendicitis,  for  which  it  may  be  mis- 
taken. Given  a  case  of  gonorrhoeal  infection  of  the  genitals  in  chil- 
dren, with  sudden  abdominal  pain,  fever,  and  general  abdominal 
distention,  the  diagnosis  presents  no  difficulties. 

Prognosis.- — The  French  writers  insist  that  the  prognosis  of  gon- 
orrhoeal peritonitis  is  benign.  On  the  other  hand,  such  a  prognosis 
will  depend  very  much  on  the  severity  of  the  infection.  Inasmuch 
as  I  have  personally  seen  three  fatal  cases  found  at  autopsy  to  have 
been  due  to  gonorrhoeal  peritonitis  complicating  vulvovaginitis,  I  can- 
not regard  the  general  form  of  gonorrhoeal  peritonitis  as  anything  but 
a  grave  infection  particularly  fatal  to  children. 

Treatment. — The  treatment  of  gonorrhoeal  peritonitis  varies  ac- 
cording to  the  extent  of  the  infection.  If  the  peritonitis  is  localized 
to  the  pelvis  it  is  quite  evident  that  the  treatment  should  be  mostly  on 
the  lines  laid  down  for  the  adult  subject.  If  the  peritonitis  becomes 
general  there  will  be  a  difference  of  opinion  as  to  whether  surgical 
interference  is  necessary.  It  is  not  within  the  scope  of  this  work  to 
discuss  this  aspect  of  the  subject;  but  in  a  resume  of  the  subject  by 
Hunner  and  Harris  the  surgical  interference  in  gonorrhoeal  perito- 
nitis is  rather  discouraged.  In  general  peritonitis  of  gonorrhoeal 
nature  rest  in  bed,  hot  turpentine-stupes  alternating  every  hour  with 


572  DISEASES    OF    THE    PEBITONEUM. 

warm  stupes,  mild  catharsis,  liquid  diet,  hydrotherapy,  and  general 
medical  treatment  are  rather  to  be  advocated. 

Pneumococcal  Peritonitis. — Pneumococcal  peritonitis,  as  has 
been  stated,  may  be  primary,  and  as  such  occurs  most  frequently  from 
the  second  to  the  twelfth  year  of  life.  It  may  be  secondary  to  pul- 
monary disease,  such  as  pneumonia  or  pleurisy ;  or  may  be  primary, 
resulting  from  an  infection  of  the  peritoneum  either  through  the  blood 
or  the  genitals.  The  frequency  of  encapsulation  of  the  pus  around 
the  umbilicus  makes  the  genital  way  of  infection  very  probable. 

Symptoms. — The  course  of  the  symptoms  in  this  disease  recalls 
that  of  a  pneumonia,  by  its  sudden  onset  in  subjects  previously  in 
good  health.  There  is  a  chill,  followed  by  fever,  pain,  vomiting,  and 
some  diarrhoea.  After  a  period  of  eight  days  there  is  a  deferves- 
cence of  the  fever  and  abatement  of  the  symptoms.  The  abdomen, 
which  has  been  previously  distended  and  generally  painful,  with  all 
the  physical  signs  found  in  other  forms  of  peritonitis,  remains  large 
and  distended,  pus  accumulates,  the  umbilicus  becomes  prominent, 
and  in  this  way  we  have  a  picture  resembling  ascites  or  tuberculosis 
of  the  peritoneum.  I  have  seen  a  case  in  which  the  latter  diagnosis 
was  made.  Pus  may  break  spontaneously  at  the  umbilicus  or  per- 
forate through  the  vagina.  The  disease  is  more  frequent  in  girls 
than  in  boys,  and,  as  has  been  stated,  the  pus  has  a  tendency  to  be- 
come encysted  and  discharge  at  the  umbilicus.  The  pus  is  of  a 
creamy,  yellow  color,  without  odor. 

Michant  has  collected  33  cases  of  pneumococcal  peritonitis  occur- 
ring in  children:  27  of  these  were  girls;  22  were  encysted,  11  were 
generalized.     In  27  cases  the  disease  was  primary. 

Diagnosis. — This  form  of  peritonitis  is  naturally  mistaken  for 
peritonitis  following  appendicitis.  It  may  be  distinguished  from  the 
latter,  however,  by  its  benign  course.  The  pus,  if  it  becomes  encysted, 
may  distend  the  abdomen  to  an  enormous  extent.  I  have  seen  a  case 
in  which  the  distention  of  the  abdomen  was  enormous,  resulting  in 
the  obstruction  of  the  portal  circulation,  with  dilatation  of  the  super- 
ficial abdominal  veins.  There  was  perforation  at  the  umbilicus,  and 
a  discharge  of  several  pints  of  pus,  followed  by  recovery  of  the  patient. 
Appendicitis  is  more  acute  in  its  nature  and  does  not  extend  over  such 
a  long  period  of  time,  with  the  benign  result,  as  seen  in  this  form  of 
peritonitis. 

Tuberculosis  of  the  peritoneum  can  hardly  be  mistaken  for  this 
form  of  peritonitis.  Given  a  distention  of  the  abdomen  by  a  fluid 
pointing  at  the  umbilicus,  which  fluid  is  found  to  be  pus,  we  may 
surmise  that  there  is  a  pneumococcal  peritonitis.  A  positive  diag- 
nosis can  only  be  made  by  bacterial  examination  of  the  pus. 

Prognosis. — The  prognosis,  as  a  rule,  is  good,  for  in  most  of  the 


DISEASES    OF    TEE    PEBITONEUM.  573 

cases,  the  pus  being  encysted,  the  general  peritoneal  cavity  remains 
free  of  infection.  In  the  general  form,  however,  the  prognosis  is 
more  grave.     Of  11  cases  of  this  form  9  died  of  sepsis. 

Simple  Chronic  Peritonitis. — Although  Henoch  and  Miiller  have 
reported  cases  of  chronic  idiopathic  non-tuberculous  peritonitis,  its 
occurrence  is  still  a  matter  of  dispute.  ISTothnagel,  linger,  and 
Heubner,  while  not  denying  in  toto  its  possible  occurrence,  insist  on 
its  extreme  rarity.  The  absence  in  these  cases  of  progressive  emacia- 
tion is  no  proof  of  the  non-tuberculous  nature  of  the  affection.  The 
absence  of  the  tubercle  bacillus  in  the  abdominal  exudate  is  of  slight 
diagnostic  value.  In  29  cases  of  undoubted  tuberculosis  of  the  peri- 
toneum Herzfeld  found  the  bacillus  only  once  in  the  ascitic  fluid.  In 
some  forms  of  tuberculous  peritonitis  the  nutrition  may  not  only  be 
good,  but  there  may  be  no  history  of  tuberculosis  or  scrofulosis.  It 
is  manifest  that  under  these  conditions  it  is  impossible  to  describe  a 
disease  the  existence  of  which  is  still  in  doubt. 


SECTION  VIII. 

DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

DISEASES  OF  THE  NOSE  AND  NASOPHARYNX. 

Examination  of  the  nose  in  infants  and  children  should  first 
include  a  general  inspection  of  the  organ.  In  this  way  anv  con- 
genital deformity,  particularly  of  the  septum  nasi,  is  noted.  Some 
forms  of  congenital  syphilis  carry  with  them  a  malformation  of  the 
bony  septum,  by  which  the  bridge  of  the  nose  is  markedly  depressed 
in  very  much  the  same  manner  as  that  of  the  adult.  Deviations  of 
the  bony  septum  are  sometimes  indicated  by  an  angular  deflection 
of  the  organ  to  one  or  the  other  side.  The  interior  of  the  nares  may 
be  inspected,  as  in  the  adult,  by  elevating  the  tip  of  the  nose  upward 
and  backward,  or  by  means  of  small-sized  specula. 

One  of  the  most  useful  methods  with  the  author  of  discovering 
any  obstruction  in  the  nares,  especially  in  the  newborn  and  young 
infant,  in  whom  instruments,  such  as  specula,  cannot  be  applied,  is 
the  passage  of  a  small  probe  into  the  nares  in  a  backward  direction. 
This  procedure  is  painless,  and  in  the  majority  of  cases  will  sufiice 
to  discover  any  swelling  of  the  mucous  membrane  or  bony  obstruc- 
tion, if  such  be  present.  The  introduction  of  the  index  finger  of  one 
or  the  other  hand  into  the  nasopharyngeal  space  for  the  purpose  of 
palpating  the  walls  of  this  structure  has  been  dilated  upon  elsewhere 
in  discussing  adenoids.  In  older  children  the  inspection  of  the  pos- 
terior nasal  space  by  mirror,  if  this  is  possible,  is  much  to  be  preferred 
to  the  digital  examination. 

Acute  Nasal  Catarrh. — This  is  a  common  affection  of  infancy 
and  early  childhood.  In  the  newborn  it  follows  as  a  direct  result  of 
exposure  combined  with  infection,  either  by  the  lochia  of  the  mother 
or  uncleanliness  of  the  bath  water.  In  older  infants  and  children 
acute  coryza  occurs  sporadically  or  in  epidemic  form.  It  is  apt  to 
be  seen  at  certain  seasons  of  the  year — early  spring  or  autumn — when 
children  are  subjected  to  sudden  changes  of  temperature  of  the  outer 
air  and  that  of  the  living  apartments.  Infection  by  bacteria  plays  a 
leading  role  in  this  disease,  as  in  other  affections  of  the  nasopharynx. 
Infants  and  children  are  apt  to  be  infected  by  adults  around  them, 
especially  careless  nurses.  One  child  may  infect  the  other,  or  acute 
nasal  catarrh  may  usher  in  the  acute  infectious  diseases,  such  as 
measles,  bronchitis,   influenza,   pneumonia,   pertussis,   and   in  some 

r,74 


DISEASES    OF    TEE    NOSE    AND   NASOPHABYNX.  575 

cases  cerebrospinal  meningitis.  One  attack  of  nasal  catarrh  may 
lead  to  another,  and  thus,  in  the  end,  to  chronic  nasopharyngeal 
catarrh.  Some  infants  and  children  have  a  tendency  to  contract 
coryza  upon  the  least  exposure  to  a  cold  or  dust-laden  atmosphere. 
Such  infants  and  children  are  pale  or  rachitic  or  show  some  constitu- 
tional dyscrasia,  such  as  lymphatism. 

Symptoms. — The  symptoms  of  acute  nasal  catarrh,  or  coryza,  con- 
sist in  a  slight  discharge  of  a  serous  or  seropurulent  secretion  from 
the  nostrils.  This  discharge  may  be  thin  or  mucoid  in  consistence, 
and  may  be  small  in  quantity,  occur  in  the  early  morning,  but  slight 
in  amount  during  the  day.  There  is,  as  a  rule,  but  little  or  no  febrile 
disturbance  in  mild  cases.  In  the  severer  types  there  may  be  in- 
volvement of  the  lachrymal  ducts,  with  slight  or  marked  redness  of 
the  conjunctiva,  orbital  and  palpebral.  In  the  latter  form  there  is 
lachrymation  and  photophobia,  with  or  without  slight  febrile  move- 
ment. In  other  cases  the  infants  or  young  children  are  uneasy,  do 
not  take  their  usual  day  naps  or  their  food,  and  have  a  slight  cough. 
An  inspection  of  the  fauces  may  reveal  but  little  inflammatory  reac- 
tion, and  the  tonsils  may  be  enlarged  to  a  slight  degree.  As  a  rule, 
all  these  organs  are  drawn  into  the  picture.  In  some  cases  conjuncti- 
vitis may  be  the  first  symptom,  and  the  nasopharyngeal  catarrh  may 
follow.  Restlessness  in  some  cases  and  temporarily  high  temperature 
are  explained  by  an  inspection  of  the  drumhead  of  the  ears,  which 
may  be  slightly  or  even  markedly  red  without  bulging  of  that  struc- 
ture. In  other  words,  a  myringitis  may  give  rise  to  a  temperature 
of  short  duration. 

Course. — As  a  rule,  the  affection  is  self-limited,  lasts  two  or  three 
days,  and  then  retrogrades ;  in  other  cases  the  physician  is  annoyed 
at  the  persistence  with  which  certain  symptoms  continue  and  refuse 
to  recede  with  therapeutical  measures.  When  the  symptoms  are 
apparently  subsiding  the  temperature  may  suddenly  rise  to  104°  T., 
and  this  in  the  face  of  the  most  trivial  physical  signs.  In  such  cases 
an  inspection  of  the  ear-drum  may  reveal  a  slight  or  marked  otitis. 
In  the  nursing  infant  the  obstruction  and  swelling  in  the  nose  may 
cause  difficulties  in  nursing,  and  the  bowels  may  show  slight  evidences 
of  infection,  caused  by  the  infant  swallowing  the  discharges  from  the 
nasopharynx. 

Diagnosis. — This  is  not  difficult,  but  in  the  face  of  any  coryza 
of  an  acute  type  the  patients  should  be  examined  as  to  the  presence 
or  absence  of  measles,  bronchitis,  pneumonia,  or  otitis,  especially  if 
a  temperature  of  a  high  intermittent  type  is  present  after  the  second 
day  of  the  disease. 

Prognosis. — The  prognosis  is  good,  but  it  is  not  invariably  so,  as 
to  a  rapid  termination  in  an  uncomplicated  recovery.     During  the 


576  DISEASES    OF    TEE    BESPIBATOBY    SYSTEM. 

early  spring  an  acute  coryza  is  not  infrequently  followed  by  an  otitis, 
which  may  be  catarrhal,  purulent,  or  even  eventually  involve  the 
mastoid.  We  should  therefore  not  regard  lightly  any  coryza  in  an 
infant  if  the  symptoms  persist  beyond  the  third  day,  and  other  organs, 
such  as  the  ears  or  bronchi,  become  involved. 

Treatment. — The  mild  forms  of  acute  nasal  catarrh  in  infancy  and 
childhood  are  self-limited  as  to  duration,  and  simple  cleanliness  with 
nursing  will  in  most  cases  suffice  in  the  treatment  of  the  disease.  In 
infants  the  nose  should  be  carefully  cleansed  with  a  spud  of  cotton 
after  the  morning  bath,  and  then  a  drop  of  castor  oil  allowed  to  flow 
back  into  the  nares.  If  this  one  application  does  not  suffice  to  keep 
the  nares  clear  of  secretion,  and  nursing  is  difficult  on  account  of  the 
accumulation  of  secretion  in  the  nares,  this  procedure  must  be  re- 
peated during  the  day.  Mild  cases  need  no  medicinal  treatment.  If 
the  throat  is  drawn  into  the  picture,  a  small  dose  of  2  or  3  minims 
of  the  tincture  of  the  chloride  if  iron  combined  with  glycerin  may 
be  given  every  three  hours.  If  there  is  much  conjunctivitis  a  satu- 
rated solution  of  boric  acid  flushed  in  the  eye  two  or  three  times  daily 
is,  as  a  rule,  efficient;  and  in  the  subacute  stages  of  the  conjunctivitis 
a  drop  of  a  solution  of  sulphate  of  zinc,  2  grains  to  the  ounce,  may  be 
instilled  into  the  eye  once  or  twice  daily. 

The  application  of  a  copper  pencil  to  the  conjunctivae  once  in  the 
subacute  state  is  advised  by  some,  though  the  author  thinks  that  such 
procedure  should  be  carried  out  by  the  oculist.  The  reaction  which 
follows  the  application  of  copper  subsides  soon,  to  leave  the  con- 
junctivae in  a  less  angry  condition.  If  an  inspection  of  the  ear-drum 
shows  a  redness  without  bulging  of  the  drumhead,  we  may  temporize, 
and  if  there  is  reason  to  believe  that  pain  is  present,  a  drop  of  warm 
hyoscyamus  oil  instilled  into  the  ear  once  or  twice  daily  will  give 
relief.  Marked  otitis  requires  more  elaborate  treatment,  which  should 
be  carried  out  by  the  otitic  specialist. 

Sprays  and  douches  are  not  applicable  to  infants  and  young  chil- 
dren, on  account  of  the  resistance  made  by  these  patients  to  any 
therapy  of  this  kind.  Only  older  children  can  be  taught  to  gargle 
or  spray.  Where  this  is  possible  a  mild  solution  of  listerine  or 
Dobell's  solution  is  all  that  is  called  for.  I  have  never  found  it 
necessary  to  use  stronger  drugs  in  children.  If  temperature  is  not 
present,  the  open  air  is  certainly  not  contraindicated ;  on  the  con- 
trary, it  may  cut  short  a  rebellious  catarrh. 

Chronic  Nasal  Catarrh.. — This  is  a  condition  found  in  infants 
and  children,  as  a  result  of  repeated  attacks  of  acute  nasal  catarrh, 
in  a  constitution  undermined  by  a  pre-existent  dyscrasia,  such  as 
lymphatism.  In  most  infants  and  children  this  tendency  to  chronic 
catarrh  is  hereditary.     There  are  evidences  in  these  little  ones  of 


DISEASES    OF    THE   NOSE   AND   NASOPHABYNX.  577 

similar  conditions  elsewhere.  Such  infants  and  children  may  suffer 
from  forms  of  conjunctivitis.  Keratitis,  dermal  eczema,  or  erup- 
tions of  various  kinds,  anaemia,  adenoids,  nasal  polypi,  deviated  nasal 
septum — may  be  combined  v^ith  hypertrophy  of  the  nasal  mucous 
membrane.  A  chronic  nasal  discharge  is  present,  and  with  it  erosion 
of  the  nostrils  and  a  distinct  odor  to  the  breath  (ozsena).  The  tonsils 
in  this  stage  are  enlarged.  Foreign  bodies  may  set  up  a  chronic 
inflammatory  condition  of  the  nares  in  children  suffering  from  chronic 
catarrh;  this  fact  must  never  be  lost  sight  of. 

Sjnnptoms. — Symptoms  of  chronic  nasal  catarrh  are  combined 
with  certain  chronic  hypertrophic  conditions  of  the  throat  and  naso- 
pharynx. Thus,  very  young  infants,  unless  they  are  subjects  of 
syphilis  or  adenoids,  are  not  chronic  sufferers  from  nasal  catarrh. 
There  is  then  a  constant  discharge  from  the  nose  and  the  nasopharynx. 
In  older  children,  from  five  to  eight  years  of  age,  the  hypertrophy 
of  the  nasal  mucous  membrane  and  the  nasopharynx  results  in  a 
profuse  mucopurulent  secretion  in  the  pharynx  and  nose. 

These  children  have  a  constant  cough,  and  are  subject  to  repeated 
attacks  of  so-called  cold,  the  tonsils  being  enlarged,  the  lymph-nodes 
at  the  angle  of  the  jaw  are  also  enlarged,  as  also  the  nodes  of  the 
neck  behind  the  sternomastoid  muscle,  and  elsewhere  in  the  body. 
The  alse  nasi  are  thickened  and  reveal  erosions.  The  lips  are  also 
thickened  as  the  result  of  obstructed  circulation.  Breathing  is  mostly 
oral.  An  inspection  of  the  fauces  shows  the  posterior  pharyngeal 
walls  coated  with  mucopus  and  studded  with  hypertrophied  struc- 
tures made  up  of  lymjjhoid  tissue  called  follicles.  In  older  children 
these  symptoms  may  be  combined  with  symptoms  of  atrophic  rhinitis, 
in  which  the  mucous  membrane  of  the  nose  loses  its  hypertrophic 
appearance  and  becomes  thin,  atrophic,  and  coated  with  dry  greenish 
crusts.  Instead  of  obstruction  there  is  found  a  wide  nasal  passage, 
and  there  is  distinct  odor  to  the  breath  and  nasal  discharges.  There 
are  forms  of  chronic  nasal  catarrh  in  which  the  above  symptoms  are 
present  to  a  very  mild  degree. 

Thus,  with  the  nasal  catarrh  there  are  enlarged  tonsils  and  a  few 
adenoids,  and  only  an  occasional  odor  to  the  breath.  This  condition 
is  found  in  children  who  have  been  treated  with  indifferent  success. 
The  very  marked  cases  of  nasal  catarrh  in  lymphatic  subjects  may 
be  combined  with  a  conjunctivitis  of  a  chronic  type  or  granular  lids 
and  eruptions,  such  as  ecthyma  and  pustular  eczema  of  the  chronic 
type,  all  of  which  indicate  the  presence  of  a  dyscrasia. 

Treatment. — The  treatment  of  the  above  conditions  are  first  local ; 
the  tonsils  and  growths  in  the  nasopharynx  must  either  be  removed 
or  treated  locally.  The  minutiae  of  such  treatment  belongs  to  the 
realm  of  nasal  specialism.     The  local  treatment  must,  however,  be 

37 


578  DISEASES    OF    THE    EESPIEATOBT    SYSTEM. 

combined  witli  general  constitutional  livgiene  and  treatment.  The 
remedies  best  suited  to  the  conditions  above  are  discussed  under  the 
heading  of  Scrofulosis  and  Ljmphatisni. 

Diphtheritic  Rhinitis. — An  apparent  simple  rhinitis  of  a  catarrhal 
character  may  in  a  short  time  take  on  the  characteristics  of  a  diph- 
theritic process,  due  to  an  infection  with  the  Klebs-Loffler  bacillus. 
There  is  a  profuse  seropurulent  or  serosang-uinolent  discharge  from 
the  nose,  with  shreds  of  pseudomembrane,  erosions  of  the  nares,  and 
extension  of  the  membrane  backward  to  the  nasopharynx  and  down- 
ward to  the  larynx.  This  true  diphtheria  is  accompanied  by  the 
glandular  swellings  and  constitutional  symptoms  characteristic  of 
the  disease  elsewhere.  On  the  other  hand,  there  is  a  form  of  rhinitis 
called  pseudomembranous  rhinitis,  in  which  the  disease  remains 
fairly  limited  to  the  nose. 

There  are  two  forms  of  pseudomembranous  rhinitis,  the  truly 
diphtheritic  form,  in  which  the  Klebs-Loffler  bacillus  is  an  etiological 
factor,  and  the  streptococcal  form,  both  of  which  have  a  similar 
symptomatology.  The  form  of  disease  to  which  we  refer  is  mild  in 
its  course,  and  begins  like  a  catarrhal  rhinitis,  but  on  the  third  day 
a  white  coating  is  formed  over  most  of  the  inflamed  area ;  that  is, 
on  the  turbinated  bodies  and  the  septum  of  the  nose.  This  coating, 
which  is  pseudomembrane,  cannot  be  either  washed  off  or  Aviped 
away  with  absorbent  cotton,  but  may  be  peeled  off  with  the  forceps. 
As  soon  as  the  membrane  is  removed,  however,  it  reforms ;  it  is  dead 
white  and  opaque,  and  firmly  attached  to  the  parts  beneath,  and, 
when  detached,  considerable  violence  must  be  used,  and  a  bleeding 
surface  is  left. 

Treatment. — In  some  cases  easts  of  pseudomembrane  may  be  re- 
moved from  the  nostrils.  Chapin,  Bresgan,  Schuler,  Hartmann, 
and  Muldenhauer  have  all  described  these  cases.  This  membranous 
condition  lasts  in  some  cases  from  twelve  to  fourteen  days,  and 
though,  as  has  been  intimated,  some  of  them  must  be  looked  upon  as 
true  diphtheria,  the  prognosis  is  generally  good.  In  the  streptococcal 
cases  the  prognosis  also  is  good.  We  must  never  forget,  however, 
that  though  there  is  in  a  certain  ])roportion  of  cases  of  membranous 
rhinitis  very  few  constitutional  symptoms,  and  very  little  tendency 
of  the  disease  to  spread  dowmward  from  the  nasopharynx  to  the 
larynx,  these  cases  should  always  be  examined  for  the  presence  of 
the  Klebs-Loffler  bacillus,  and  if  found  sh<;)uld  bo  treated  as  a  diph- 
theritic process. 

Foreign  Bodies  in  the  Nose. — Children  are  prone  to  put  beans, 
buttons,  pins,  and  foreign  bodies  of  all  kinds  into  their  noses.  These 
foreign  bodies  at  first  cause  little  disturbance ;  after  awhile,  however, 
they  become  a  source  of  pain  and  irritation,  and,  if  not  discovered, 


DISEASES    OF   THE   NOSE   AND   NASOPHABYNX.  579 

chronic  nasal  catarrh,  ulceration,  and  even  abscess  may  result.  The 
removal  of  foreign  bodies  from  the  nose  in  many  cases  requires  noth- 
ing more  than  ordinary  skill.  Some  children  can  be  taught  to  blov9" 
the  foreign  body  out  of  the  nostril  by  occluding  the  unobstructed 
nostril  with  the  fingers.  In  other  cases  the  foreign  body  can  be  re- 
moved with  the  forceps.  In  the  third  set  of  cases,  a  scoop  introduced 
into  the  nostril  so  as  to  hook  the  body  posteriorly  is  an  efficient  means 
to  remove  it ;  in  other  words,  a  bent  probe  or  buttonhook. 

Epistaxis.- — Epistaxis  is  rare  in  the  newborn,  except  as  a  mani- 
festation of  syphilis  or  sepsis.  In  infants  and  children  it  may  be 
caused  by  traumatism  of  any  kind,  and  is  seen  mostly  in  school  chil- 
dren who  have  been  confined  in  warm  rooms  and  have  developed 
nasal  catarrh  with  or  without  adenoid  vegetations.  There  may  be  in 
these  cases  small  ulcers  or  erosions  of  the  septum  nasi.  Epistaxis 
occurs  in  the  course  of  acute  or  chronic  rhinitis,  typhoid  fever,  pneu- 
monia, infectious  diseases,  diseases  of  the  heart,  chlorosis,  haemophilia, 
scurvy,  morbus  maculosus,  and  finally,  it  occurs  in  young  girls  enter- 
ing on  the  period  of  menstrual  activity.  It  may  occur  in  these  sub- 
jects also  as  a  vicarious  form  of  menstruation. 

Epistaxis,  as  a  rule,  is  unaccompanied  by  any  symptoms  other 
than  those  of  the  bleeding,  in  drops,  from  the  nose.  In  very  few 
cases  does  this  hemorrhage  become  alarming  unless  there  is  a  history 
of  hsemophilia.  The  quantity  of  blood  lost  is  often  exaggerated  by 
the  patients,  and  rarely  exceeds  an  ounce.  K^asal  hemorrhage  may 
occur  daily,  or  it  may  recur  every  few  days  or  weeks,  in  which  case 
there  is  always  a  suspicion  either  of  traumatism,  such  as  picking  the 
nose,  or  a  chronic  nasal  catarrh.  Some  children  complain  of  dizzi- 
ness or  vertigo  preceding  the  attack.  Others  become  greatly  alarmed 
by  the  sight  of  blood. 

Children  below  the  age  of  three  or  four  years  rarely  have  epis- 
taxis except  as  a  result  of  traumatism  or  nasal  ulceration.  In  some 
cases  hemorrhage  is  really  alarming,  amounting  to  a  rhinorrhagia. 
In  these  cases  there  is  a  suspicion  of  dyscrasia ;  in  many  cases  blood 
may  during  sleep  flow  down  the  posterior  nares  into  the  oesophagus 
and  stomach,  and  after  a  time  the  clotted  blood  may  be  vomited  or 
passed  in  the  movements,  thus  simulating  hemorrhage  from  the 
stomach  or  bowels,  and  in  young  infants  melsena. 

Adenoid  Growths  {Adenoid  Vegetations). — Adenoid  growths  are 
masses  of  hypertrophied  lymphoid  tissue  found  in  the  vault  of  the 
nasopharynx.  In  1868  Meyer  of  Copenhagen  first  drew  attention 
to  adenoid  growths  as  a  clinical  entity.  Since  then  the  increased 
importance  of  a  recognition  and  study  of  these  growths  has  become 
quite  evident. 

Occurrence. — They  occur  in  persons  of  all  climes  and  countries  but 


580 


DISEASES    OF    THE    BESPIRAIOEY    SYSTEM. 


Fig.  116. 


are  less  prevalent  in  warm  climates  and  in  high  and  dry  mountainous 
districts  than  in  cold  and  damp  countries.  The  adenoid  growths 
occur  at  all  ages  from  the  newborn  infant  to  old  age.  The  greatest 
frequency  according  to  all  statistics  is  from  the  sixth  to  the  tenth 
year  of  life.  Of  4000  cases  Wingrave  found  1144  to  occur  at  this 
period  of  childhood. 

Situation. — Adenoid  growths  are  found  on  the  posterior,  superior 
and  lateral  walls  of  the  nasopharynx.  They  are  met  most  frequently 
in  the  so-called  fornix  of  this  space.  They  may  he  grouped  around 
the  openings  of  the  Eustachian  tubes.  They  have  a  crostate,  cylin- 
drical or  flat  form.  They  thus  are  nothing  more  or  less  than  the 
hypertrophied  pharyngeal  or  Luschka's  tonsil  (Fig.  116). 

Etiology. — The  true  cause  of 
adenoid  growths  is  still  a  matter 
of  speculation.  They  are  found 
both  in  breast-fed  and  artificially 
fed  children,  but  undoubtedly  ac- 
company a  so-called  lymphatism 
prevalent  in  some  families  as  well 
as  children.  There  is  also  a  heredi- 
tary element  in  the  etiology  of 
many  cases.  An  infection  of  some 
kind  is  the  starting  point.  This 
results  in  a  chronic  catarrh  of  the 
nasopharynx  w^hich  favors  hyper- 
trophy' of  adenoid  tissue.  If  the 
nasal  and  pharyngeal  passages  are 
congenitally  narrow  and  conditions  are  not  favorable  to  the  clear- 
ing out  of  contained  secretions,  then  the  elements  arise  which  favor 
hypertrophy  in  keeping  alive  inflammatory  conditions  in  those  parts. 
An  investigation  into  their  nature  by  Macfayden  and  Macconkey 
has  revealed  the  occasional  presence  of  tubercle  bacilli,  but  not  to 
any  greater  extent  than  would  be  called  accidental,  in  the  face  of 
tubercle  bacilli  in  neighboring  organs,  such  as  the  lungs  or  larynx. 
The  acute  infectious  diseases,  such  as  measles,  scarlet  fever,  diph- 
theria, or  any  disease  in  which  there  is  accompanying  catarrh  and 
inflammation  of  the  tonsils  and  structure  of  the  nasopharynx,  are 
followed  by  a  subacute  catarrhal  condition  of  these  parts  which  ulti- 
mately results  in  the  formation  of  adenoid  growths  and  enlarged 
tonsils. 

Symptoms. ^ — The  symptoms  may  be  grouped  under  four  heads: 
rhinitis  or  nasal  discharge,  snoring,  mouth-breathing,  and  vocal 
defects. 

Rhinitis. — A  nasal  discharge  is  a  constant  symptom  of  adenoids. 


Adenoid  growth  with  centimetre  scale. 
Shows   lobulated   structure. 


DISEASES    OF    THE    NOSE    AND   NASOPHARYNX. 


581 


Even  to  a  mild  degree  it  may  be  looked  upon  as  presumptive  evidence 
of  their  presence.  With  the  nasal  catarrh  and  discharge  there  are 
also  attacks  of  epistaxis  and  earache  which  will  be  taken  up  later. 

Mouth-hreathing. — Mouth-breathing,  both  by  day  and  night,  is 
almost  a  pathognomonic  symptom.  The  peculiar  condition  of  the 
mouth  leads  to  a  sort  of  adenoid  facies,  which  is  quite  characteristic 
and  easily  recognized.  With  the  facies,  the  open  mouth,  the  thick 
lips,  the  sunken  alse  nasi,  and  in  some  cases  eroded  nostrils,  the  pic- 
ture of  the  adenoid  sufferer  is  complete  (Fig.  117). 

Fig.  117. 


Children  with  adenoid  growths,  marked  and  moderate  in  degree. 

Snoring. — Snoring,  which  occurs  at  night  and  in  young  infants, 
is  a  rattling  noise  in  the  throat  which  is  due  to  ineffectual  attempts 
at  breathing. 

Speech. — The  speech  is  affected  and  thick,  the  niceties  of  pronun- 
ciation in  forming  the  letters  m,  s,  ng,  etc.,  are  lost  in  an  altered 
substitute  which  is  more  easily  formed  by  the  obstructed  nasal  and 
pharyngeal  spaces.  With  the  obstruction  of  the  nasal  passages  comes 
an  uneasy  sleep  and  restlessness  at  night,  with  accompanying  night- 
terrors. 

Lymphcitism. — Many  or  most  of  these  cases  are  anaemic,  the 
anaemia  being  in  part  an  expression  of  the  general  constitutional  con- 
dition of  lymphatism. 

Deafness. — Deafness  is  a  final  result  of  the  ill  effects  of  adenoids 
allowed  to  continue  without  treatment.  Of  deaf  mutes  fully  17  to 
70  per  cent,  have  adenoids. 

Children  suffering  from  adenoids  hear  very  imperfectly  at  times 
and   at  others   quite  well.      This  is  traceable  to  the   condition  of 


582 


DISEASES    OF    THE    BESPIBATOB¥    SYSTEM. 


catarrh  in  the  nasopharynx  as  affecting  the  Eustachian  tubes.  Otitis 
is  a  frequent  accompaniment  of  adenoids  and  recurrent  otitis  with 
persistent  nasal  discharge  is  not  uncommon. 

Bronchitis. — In  some  cases  the  chronic  catarrhal  conditions  in  the 
nasopharynx  cause  a  constant  hacking  cough  and  in  many  cases 
the  catarrh  passes  down  the  respiratory  passages,  giving  rise  to  bron- 
chitis or  bronchitis  of  a  chronic  type,  with  emphysema  and  asthmatic 
attacks. 

Classes  of  Cases. — Clinically  there  are  three  distinct  classes  of 
cases  that  suffer  from  adenoids : 

The  first  class  comprises  those  in  which  the  adenoids  cause  few 
or  no  symptoms.  The  children  when  in  good  health  breathe  through 
the  nose  and  keep  the  mouth  closed  during  sleep.  They  are  pecu- 
liarly susceptible  to  slight  colds  or  catarrh,  and  when  thus  affected 

Fig.  118. 


Enlarged    tonsils    enucleated    entire    in    case    with  concomitant   adenoid  growths. 

the  tonsils  enlarge,  the  nose  becomes  obstructed  by  secretion,  there  is 
difficulty  in  breathing,  and  the  patient  sleeps  with  open  mouth.  On 
the  subsidence  of  the  inflammatory  condition  the  normal  status  is 
re-established.  The  children  are  subject  to  recurrent  attacks  of  ton- 
sillitis, and  with  each  recurrence  the  symptoms  of  adenoids  become 
more  marked.  The  patients  contract  obstinate  coughs  which  resist 
all  treatment,  and  epistaxis  occurs  from  causes  apparently  trivial. 

The  second  class  of  cases  comprises  those  in  which,  in  addition 
to  enlarged  tonsils,  there  are  enlarged  lymph-nodes  in  various  regions 
of  the  body.  The  patients  are  pale  and  present  all  the  symptoms 
of  lymphatism.  Their  voices  have  a  nasal  intonation,  the  lips  are 
always  parted,  and  they  sleep  with  the  mouth  open  (mouth-breathers). 

The  third  class  comprises  the  extreme  cases  of  adenoids.  The 
nasal  passages  are  the  seat  of  a  chronic  hypertrophic  rhinitis,  the 
tonsils  are  enlarged,  there  is  obstructed  breathing,  and  the  mouth  is 
always  open.  The  infants  and  children  make  a  peculiar  snarling 
sound  in  breathing  and  have  a  stupid  look.  They  are  not  neces- 
sarily lymphatic.  Many  children  suffering  from  adenoids  are  slightly 
deaf,  and  all  are  subject  to  repeated  catarrhal  attacks  (Fig.  118). 


DISEASES    OF    THE    NOSE    AND    NASOPHARYNX. 


583 


Between  the  extremes  are  seen  all  gradations  of  the  affection. 
Many  children  who  suffer  from  adenoids  are  well  developed  and  in 
other  respects  perfectly  normal.  The  deformities  of  the  chest  which 
have  been  ascribed  to  adenoids  can  hardly  be  so  regarded.  They  are 
coincidental.  Many  of  them  are  due  to  rachitis  in  early  life  and  to 
unhygienic  living.  To  trace  enuresis,  chorea,  and  masturbation  to 
the  presence  of  adenoids,  seems  also  somewhat  extreme.     Adenoids 

Fig.  119. 


Examination  for  adenoid  growtlis.      Position  of  patient  and  examiner. 

are  an  obstruction  to  the  breathing,  a  menace  to  the  hearing,  and  also 
a  focus  for  repeated  infections  of  the  nasopharynx  or  the  ears.  These 
are  sufficient  reasons  for  their  removal. 

Diagnosis. — The  diagnosis  is  not  difficult  from  the  above  set  of  symp- 
toms. jSTasal  polypi  in  older  children,  if  they  exist,  may  be  seen  in 
the  nasal  passages.  A  fibroid  tumor  of  the  nasopharynx  is  hard  and 
a  malignant  growth  is  scarcely  probable  as  it  is  rare  in  infancy  and 
childhood  and  gives  a  series  of  quite  distinctive  symptoms.  There 
are  enlarged  tonsils ;  they  are  probably  accompanied  by  adenoids.     If 


584  DISEASES    OF    TEE   BESPIBATOBY    SYSTEM. 

on  inspection  of  the  posterior  nasopharyngeal  wall  there  is  an  en- 
largement of  the  follicular  adenoid  structure  of  the  mucous  mem- 
brane it  may  well  be  surmised  that  adenoids  exist  higher  up. 

Method  of  Examination. — An  inspection  of  the  nasopharynx  may 
be  made  by  the  rhinoscopic  mirror  or  the  nasopharyngoscope,  recently 
devised  by  Hays,  or  by  digital  exploration.  Rhinoscopy  is  only 
feasible  in  older  tractable  children,  as  is  also  the  nasopharyngoscopy. 
Accordingly,  in  infants  and  children  the  digital  exploration  alone  is 
feasible.  The  finger-nail  of  the  index  finger  of  the  right  hand  is 
scrupulously  cleaned  and  trimmed  so  as  not  to  traumatize  the  parts 
and  infect  them.  The  physician  "  stands  behind  the  patient,  who  is 
seated  in  a  chair.  The  child  is  told  to  open  the  mouth  and  the 
thumb  of  the  left  hand  presses  the  left  cheek  between  the  teeth.  The 
index-finger  of  the  right  hand  is  carried  round  the  soft  palate  into 
the  nasopharynx  where  the  finger  will  come  in  contact  (if  adenoids 
be  present)  with  a  variable  soft  mass  which  bleeds  readily.  With 
practice  this  examination  can  be  conducted  so  expeditiously  that  the 
child  has  not  got  time  to  struggle  or  get  frightened"  (G.  A.  G. 
Simpson)   (Fig.  119). 

Indications  for  Operation. — ISTursing  infants  who  cannot  nurse  or 
in  whom  sleep  is  palpably  disturbed  should  be  operated  upon  without 
delay,  as  in  these  patients  the  operation  is  simple  and  is  followed  by 
immediate  relief.  The  indications  for  removal  of  the  growths,  even 
if  only  small  amounts  of  adenoid  tissue  are  present,  are  in  older  chil- 
dren a  persistent  rhinitis  or  repeated  attacks  of  acute  rhinitis,  inter- 
mittent attacks  of  deafness  with  pale  retracted  ear-drums,  or  exuda- 
tive catarrh  of  the  middle  ear,  chronic  aural  discharge  which  will 
not  improve,  mouth-breathing,  snoring  at  night,  and  backwardness  in 
phonation ;  in  young  children  a  persistent  dry  cough  or  bronchitis 
or  an  irritable  cough.  Of  great  importance  is  the  recognition  of  the 
fact  that  some  obstinate  ear-discharges  will  not  yield  to  treatment 
until  existing  adenoids  be  removed. 

Prognosis. — The  operation  for  the  removal  of  adenoids  is  exceed- 
ingly simple  and  unaccompanied  by  danger  to  life.  It  should  be 
borne  in  mind  that  any  operation  of  this  nature  may  be  followed 
by  infections,  especially  of  the  ears.  In  this  respect  no  operator  is 
exempt  from  the  chagrin  of  finding  occasionally  a  complicating 
otitis  follow  the  operation.  Adenoids  are  apt  to  "return"  or  grow 
after  being  removed ;  a  secondary  operation  then  becomes  necessary. 

Treatment. — When  the  diagnosis  of  adenoids  has  once  been  made, 
it  is  well  not  to  temporize  with  douches  and  sprays,  as  this  mode  of 
treatment  acts  only  in  a  cleansing  manner  and  merely  delays  the 
ultimate  necessity  of  removing  the  growths.  This  removal  is  so 
much  in  the  domain  of  specialistic  procedures  that  it  is  well  for  the 


DISEASES    OF    TEE   NOSE    AND   NASOPHABYNX.  585 

practitioner  not  to  rely  entirely  on  descriptive  methods  but  to  see,  if 
he  can,  the  operation  performed  once  or  twice  by  an  expert  before 
resorting  to  a  personal  attempt. 

Contraindications  to  0 iterations. — The  tonsils  and  adenoids  being 
portals  of  infection,  there  are  certain  states  in  which  operations  in 
this  region  may  be  followed  by  reinfection.  Thus  cases  of  chorea 
with  endocarditis,  if  still  active,  should  not  be  subjected  to  operation. 
The  chorea  is  likely  to  recur  with  gTeater  severity,  and  the  danger 
of  a  renewed  heart  lesion  is  great.  Children  who  are  in  the  active 
stages  of  endocarditis  or  recently  recovered  should  not  be  operated 
upon.  In  all  these  cases  palliative  measures,  such  as  sprays  and 
douches,  should  be  employed  until  the  conditions  above  mentioned 
are  thoroughly  quiescent.  In  one  case  of  chorea  I  saw  an  operation 
for  adenoids  followed  in  three  days  by  a  chill  and  high  fever,  endo- 
pericarditis,  chorea  insaniens,  and  death  within  ten  days.  While 
such  cases  are  exceptional,  they  teach  the  necessity  of  caution  in 
deciding  to  operate  upon  the  adenoids  in  chorea  and  heart  cases. 

Acute  Retropharyngeal  Abscess  {Idiopathic  Retropharyngeal 
Abscess;  Retropharyngeal  Lymphadenitis).  —  The  retropharyngeal 
space,  according  to  Gillette,  is  the  seat  of  lymph-nodes,  which  are 
intimately  connected  with  the  lymph-vessels  and  lymph-spaces  of 
the  tonsils,  and  also  with  the  system  of  lymph-vessels  of  the  soft 
palate,  these  being  also  connected  with  the  deep  lymph-nodes  of  the 
face  and  neck.  Processes  such  as  catarrhal  angina,  diphtheria,  scar- 
let fever,  measles,  or  any  lesion  of  the  mouth,  are  likely  to  involve 
the  retropharyngeal  nodes  (Karewski).  Sometimes  only  the  lymph- 
nodes  in  the  median  line  of  the  retropharynx  opposite  the  base  of 
the  tongue  are  affected.  In  this  form  the  tumor  in  the  midline  is 
seen  when  the  mouth  is  opened.  In  other  cases  several  lymph-nodes 
are  involved,  and  the  process  is  then  seen  both  as  a  swelling  in  the 
mouth  and  as  an  external  swelling  at  the  side  of  the  neck. 

The  swelling  appears  at  or  beneath  the  angle  of  the  jaw,  in  front 
of  or  behind  the  sternomastoid  muscles.  Retropharyngeal  abscess 
may  occur  in  the  foUovdng  forms : 

1.  Acute  retropharyngeal  abscess : 

a.   That  which  points  wholly  in  the  mouth. 

h.   That  which  points  both  externally  and  internally. 

c.   That  which  forms  a  tumor  chiefly  external. 

2.  Chronic  tuberculous  retropharyngeal  abscess. 

3.  Septic  retropharyngeal  abscess. 

This  third  class  of  retropharyngeal  abscesses  are  those  which 
complicate  or  follow  the  exanthemata,  and  which  have  a  tendency 
to  burrow  downward,  bursting  into  the  mediastinum  or  to  involve 
important  structures,  such  as  the  large  arteries  in  the  neck,  thus 
causing  fatal  hemorrhage.     A  few  such  cases  occur  in  the  literature. 


586  DISEASES    OF    THE    EESPIEATOEY    SYSTEM. 

Frequency  and  Etiology. — Retropharyngeal  abscess  is  peculiarly 
a  disease  of  infancy  and  early  childhood.  The  frequency  diminishes 
in  later  childhood,  the  disease  being  rare  after  the  fifth  year.  Of 
77  of  my  cases.  4  occurred  between  the  first  to  the  third  month;  10 
between  the  third  and  the  sixth  month ;  41  between  the  sixth  and  the 
tweKth  month:  19  between  the  first  and  the  fifth  year,  and  the 
remainder  after  the  fifth  year.  One  infant  was  only  one  month  of 
age,  and  in  two  cases  the  patient  was  two  months  of  age.  The  figures 
correspond  to  those  of  Bokai.  The  frequency  in  early  infancy  is 
probably  exj^lained  by  the  structure  of  the  retropharyngeal  lymph- 
spaces  and  the  susceptibility  of  the  lymph-nodes  to  suppurative  infec- 
tions at  that  period  of  life. 

Simon  has  described  the  lymphatics  in  the  retropharyngeal  region 
of  infants  and  children  as  forming  a  small  network  of  lymph-vessels 
and  nodes  on  either  side  of  the  median  line.  This  lymphatic  net- 
work is  situated  between  the  superior  constrictor  and  the  aponeurosis 
of  the  prevertebral  muscles.  After  the  third  year  of  life  these 
lymphatics  and  nodes  are  said  to  disappear.  This  fact,  as  Blackader 
points  out,  would  indicate  a  close  connection  between  the  time  of 
activity  of  these  nodes  and  the  period  when  retropharyngeal  abscess 
is  most  prevalent.  It  would  help  also  to  explain  the  absence  of  this 
form  of  abscess  in  older  children  and  in  adults  who  are  frequently 
affected  by  tonsillar  (quinsy)  abscess. 

I  have  examined  the  pus  from  many  of  these  abscesses,  and  found 
that  it  contains  quite  uniformly  a  streptococcus  of  the  short  or  the 
long  variety,  not  as  a  rule  very  virulent.  It  may  be  assumed  that  in 
all  probability  these  bacteria  are  the  essential  cause  of  the  abscesse-s. 
They  gain  access  to  the  retropharynx  either  through  the  tonsils  or 
the  mucous  membrane  of  the  pharyngeal  space.  The  abscess  may 
thus  be  secondary  to  any  form  of  inflammation  of  these  structures. 
It  occurs  as  a  complication  of  simple  tonsillitis,  pharyngitis,  influenza, 
or  any  of  the  exanthemata. 

Symptoms. — The  symptoms  of  retropharyngeal  abscess  are  not  at 
first  distinctive.  The  development  of  the  abscess  is  insidious.  At 
the  outset  there  are  the  symptoms  of  ordinary  tonsillitis  or  pharyn- 
gitis. The  fever  is  high  at  the  beginning.  After  the  acute  symptoms 
subside  it  is  noticed  that  the  lymph-nodes  at  the  angle  of  the  jaw  con- 
tinue to  be  enlarged,  and  that  the  fever  continues  to  show  a  remittent 
type.  There  is  some  prostration,  the  infant  does  not  nurse  prop- 
erly, cries,  and  is  frequently  restless.  Inspection  of  the  throat  on  the 
fourth  or  fifth  day  of  a  tonsillitis  may  reveal  nothing  except  some 
swelling  or  oedema  of  the  posterior  pharyngeal  wall  or  of  the  pillars 
of  the  fauces,  no  tumor  being  visible.  After  an  interval  of  a  few 
days,  generally  on  the  seventh  or  eighth  after  the  initial  symptoms. 


DISEASES    OF    TEE    NOSE    AND   NASOPHABYNX.  587 

it  is  noticed  that  the  voice  of  the  infant  has  a  nasal  quality,  that  the 
head  is  thrown  back,  and  that  the  breathing  is  noisy  and  nasal. 

Examination  shows  that  the  lymph-nodes  at  the  angle  of  the  jaw 
in  front  or  behind  the  sterno-mastoid  are  swollen ;  inspection  of  the 
interior  of  the  fauces  shows  a  distinct  swelling  at  the  side  of  the 
pharynx  pushing  the  tonsil  and  pillar  of  the  fauces  of  that  side 
forward.  On  introducing  the  finger  a  tense,  fluctuating  swelling, 
which  may  reach  downward  toward  the  larynx,  can  be  felt.  In  other 
cases  there  is  very  little  external  swelling,  and  the  internal  tumor  is 
situated  nearer  the  median  line,  pushing  the  posterior  pharyngeal 
wall  forward.  This  swelling  is  covered  by  mucous  membrane,  is 
tense  and  fluctuating.  If  the  tumor  is  allowed  to  increase  in  size, 
there  is  pronounced  interference  with  the  breathing.  I  have  seen 
cases  in  rachitic  infants  in  which  the  inspiratory  sound  was  distinctly 
of  a  crowing  character,  showing  incoordinate  action  of  the  vocal  cords. 
These  cases  show  great  prostration  and  feebleness  of  pulse. 

Course. — If  not  treated,  the  abscess  may  press  on  the  larynx  and 
cause  asphyxia,  or  may  burst  spontaneously  into  the  larynx,  suffo- 
cating the  patient  if  it  occurs  during  sleep,  or  may  burst  into  the  ear 
through  the  Eustachian  tube  and  discharge  externally.  All  of  these 
results  are  rare  if  the  abscess  is  detected  in  time  for  incision. 

Diagnosis. — The  diagnosis  of  retropharyngeal  abscess  is  difiicult  to 
the  beginner,  but  is  simple  after  the  observation  of  one  or  two  cases. 
The  quality  of  the  voice  and  the  cry  are  so  characteristic  that  after 
being  once  heard  they  are  unmistakable.  The  breathing  also  is 
typical.  The  external  swelling  is  present  in  most  cases,  and  the  head 
slightly  retracted.  Finally,  digital  examination  should  always  be 
resorted  to  in  all  cases  in  which  a  slight  or  marked  internal  swelling 
is  present.  The  index  finger  of  the  right  hand  is  passed  into  the 
mouth  and  the  posterior  pharyngeal  wall  palpated.  If  an  abscess  be 
present,  it  will  be  apparent  as  a  hard  or  tense,  globular,  deep  or  super- 
ficially fluctuating  tumor.  Care  should  be  taken  not  to  mistake 
the  prominence  of  the  body  of  the  seventh  cervical  vertebra  for  an 
abscess.  The  bony  tumor  is  deeper,  as  a  rule,  than  the  retropharyn- 
geal abscess,  and  is  not  fluctuating.  All  manipulation  should  be 
carried  out  gently,  else  the  abscess  may  burst  and  suffocate  the  patient 
or  rude  exploration  may  cause  a  peculiar  form  of  collapse  which  some- 
times follows  digital  examination  in  this  region. 

Prognosis.- — The  prognosis  of  simple  acute  retropharyngeal  abscess 
is  good.  Bokai  lost  only  4  per  cent,  of  his  cases.  With  early  diag- 
nosis and  proper  treatment  recovery  is  the  rule. 

Treatment. — The  treatment  of  acute  retropharyngeal  abscess  is 
incision.  This  varies  with  the  nature  and  location  of  the  abscess. 
In  the  majority  of  cases  the  abscess  is  near  the  median  line,  and  its 


588  DISEASES    OF    THE    EESPIEATOET    SYSTEM. 

wall  is  just  beneath  tlie  surface  of  the  mucous  membrane.  An  in- 
ternal incision  will  then  afford  immediate  and  permanent  relief.  In 
other  cases  the  abscess  is  at  one  side  and  internal,  and  may  also  be 
safely  incised  from  within.  In  making  an  internal  incision  the  fol- 
lowing method  should  be  pursued :  the  child  is  wrapped  in  a  blanket 
and  held  upright  in  the  lap  of  the  nurse,  facing  a  good  light.  An 
assistant  steadies  the  head  from  behind.  The  tongue  is  depressed 
with  a  tongue-depressor,  and  a  bistoury,  with  the  edge  guarded  by 
rubber  plaster,  leaving  only  a  half  inch  of  the  tip  exposed,  is  plunged 
into  the  most  prominent  part  of  the  tumor.  When  the  pus  escapes, 
the  incision  is  enlarged  from  above  downward.  The  instrument 
should  not  be  directed  toward  the  side  of  the  neck,  for  fear  of  wound- 
ing a  vessel. 

As  soon  as  the  pus  escapes  freely  the  head  of  the  infant  is  thrown 
forward  and  the  pus  allowed  to  drain  into  a  basin,  pressure  being 
made  from  without,  on  the  side  of  the  neck.  The  internal  incision 
should  be  made  as  rapidly  and  as  gently  as  possible.  I  have  seen 
death  result  within  a  few  hours  from  aspiration  of  pus  in  a  case  in 
which  an  abscess  burst  as  a  consequence  of  rough  digital  exploration. 
If  necessary,  the  incision  may  be  enlarged  with  a  dressing-forceps. 
In  some  cases  the  wound  should  be  prevented  from  closing  by  intro- 
ducing the  forceps  daily. 

There  is  another  class  of  cases  in  which  the  deep  cervical  glands 
at  the  side  of  the  neck  are  involved  and  the  abscess  points  partly 
internally  and  partly  externally.  In  these  cases  it  is  unsafe  to  incise 
from  within,  nor  is  complete  relief  afforded  by  so  doing.  The 
abscess  should  be  approached  from  without  through  a  careful  dissec- 
tion by  a  surgeon.  The  tuberculous  abscess  is  due  to  spinal  caries. 
and  is  best  opened  and  drained  from  without,  as  are  also  septic 
abscesses. 

DISEASES  OF  THE  TONSILS. 

The  tonsils  are  really  lymph-nodes,  as  has  been  shown  by  Stohr 
and  Hodenpyle.  In  severe  forms  of  inflammation  they  are  enlarged. 
and  the  so-called  crypts  become  plugged  with  bacteria  and  the  products 
of  inflammation  (leucocytes,  fibrin,  serum).  The  crypts  appear  at 
the  surface  of  the  tonsil  as  yellowish  specks.  A  catarrhally  inflamed 
tonsil  may  not  show  them  at  the  surface,  because  the  products  of 
inflammation  do  not  coagulate,  and  are  thus  thrown  off  more  readily. 
There  is  nothing  specific  about  a  lacunar  or  follicular  amygdalitis. 
It  is  only  a  clinical  picture  of  the  large  class  of  catarrhal  inflamma- 
tions, in  all  of  which  the  crypts  and  the  tissue  of  the  tonsil  are  infil- 
trated with  inflammatory  products. 


DISEASES    OF    THE    TONSILS.  589 

Acute  Follicular  Amygdalitis  (Acute  Catarrhal  Tonsillitis;  Acute 
Lacunar  Amygdalitis;  Catar-rhal  Angina). — Acute  follicular  amyg- 
dalitis is  an  infectious  disease,  communicable  either  through  the 
secretions  or  by  direct  contact,  as  in  the  act  of  kissing.  It  occurs 
both  as  a  primary  and  as  a  secondary  affection.  As  a  primary  affec- 
tion, it  occurs  at  all  periods  of  infancy  and  childhood.  It  was 
formerly  taught  that  follicular  amygdalitis  was  rare  in  infants. 
This  is  scarcely  true.  Of  1284-  cases  of  lacunar  amygdalitis,  333 
occurred  in  infants  under  the  age  of  twelve  months,  and  76  from  the 
first  to  the  fifth  month;  of  the  latter,  only  5  occurred  in  the  first 
month.  It  is  frequent  in  children  from  the  second  to  the  fourth 
year,  but  is  more  common  after  than  before  the  fourth  year.  The 
tonsils  are  secondarily  involved  in  the  exanthemata — scarlet  fever, 
measles,  and  varicella — and  in  parotitis,  influenza,  pneumonia,  and 
pertussis.  In  all  these  affections  they  are  red,  swollen,  and  in  some 
cases  present  the  appearance  seen  in  the  typical  lacunar  type  of  the 
disease. 

Etiology. — The  predisposing  causes  of  catarrhal  tonsillitis  or 
lacunar  amygdalitis  are  exposure  to  cold,  traumatism,  and  the  swal- 
lowing of  corrosive  or  irritant  substances.  The  exciting  causes  of 
follicular  or  lacunar  amygdalitis  and  catarrhal  amygdalitis  are  the 
Streptococcus  pyogenes,  the  Staphylococcus  pyogenes,  and  the  pneu- 
mococcus.  The  diplococcus  described  by  E,oux  is  also  found  in  the 
tonsillar  crypts. 

Symptoms.— The  affection  rarely  begins  with  a  chill.  The  infant 
is  restless,  peevish,  and  wakeful  at  night ;  it  breathes  rapidly,  and 
there  are  high  fever  and  marked  prostration.  ISFursing  is  interfered 
with,  not  only  on  account  of  the  pain  in  swallowing,  but  because  in 
the  majority  of  cases  there  is  more  or  less  rhinitis.  The  bowels  are 
disturbed  as  a  result  of  swallowing  infectious  secretions  from  the 
mouth  with  the  food.  The  action  of  the  bacteria  is  manifested  in 
green  stools,  which  are  frequent  and  watery.  Inspection  of  the 
throat  should  be  conducted  with  patience  and  in  a  good  light.  The 
tonsils,  normally  very  small,  are  seen  to  be  enlarged  and  studded  with 
whitish  or  yellowish-white  points.  The  lymph-nodes  at  the  angle  of 
the  jaw  may  be  enlarged. 

In  older  infants  and  children  the  tonsils  are  enlarged,  and  the 
crypts  plugged  with  inflammatory  products.  The  surface  of  the 
tonsils  is  covered  with  mucopurulent  exudate,  or  there  may  be  a  small 
necrotic,  ulcerated  area  in  one  of  the  tonsils.  The  neighboring  struc- 
tures, such  as  the  uvula,  the  pharyngeal  mucous  membrane,  the 
pillars  of  the  fauces,  and  even  the  larynx,  may  share  in  the  catarrhal 
inflammation.  The  lymph-nodes  at  the  angle  of  the  jaw  may  be 
enlarged.     The  fever,  as  a  rule,  is  high  at  first,  ranging  from  104° 


590  DISEASES    OF    THE    BESPIBATOBY    SYSTEM. 

to  105°  F.  (40°  to  40.5°  C.)  or  above.  The  pulse  is  correspondingly 
rapid,  and  the  respirations  may  be  increased  in  frequency. 

The  duration  of  a  typical  case  of  primary  tonsillitis  varies.  As 
a  rule,  the  temperature  remains  high  for  tv\^o  or  three  days,'  with 
daily  remissions.  It  then  subsides  and  the  patient  convalesces.  In 
some  cases  the  temperature  continues  high  for  five  or  ten  days,  and 
then  drops.  In  all  of  these  cases  there  is  some  latent  or  apparent 
complication,  such  as  retropharyngeal  abscess,  otitis,  or,  as  has  been 
recently  pointed  out  by  Packard  and  others,  an  insidious  endocarditis. 

When  otitis  supervenes  the  tonsillar  affection  subsides.  The 
fever,  however,  continues,  with  daily  remissions.  Infants  and  young 
children  do  not  indicate  the  existence  of  pain  in  the  ear.  The 
patient  is  restless  at  night,  and  wakes  with  a  start  or  in  a  peevish 
mood.  In  many  cases  the  otitis  can  be  diagnosed  only  by  exclusion. 
In  other  cases  the  temperature  continues  high  for  a  week  or  longer, 
reaching  103.5°  F.  (39.7°  C.)  during  the  day.  The  infant  seems 
weaker,  the  tonsils  are  not  enlarged  or  severely  inflamed,  the  pulse  is 
accelerated,  and  the  respirations  may  number  40.  In  such  cases  the 
lungs  show  no  sign  of  involvement,  but  careful  examination  of  the 
heart  will  often  reveal  the  presence  of  a  systolic  murmur  at  the  apex 
and  a  slight  increase  of  the  area  of  cardiac  dulness  beyond  the  nipple. 
These  are  the  so-called  rheumatic  cases.  Frequently  the  urine  shows 
a  trace  of  albumin.  In  rare  cases  it  contains  in  addition  to  the  albu- 
min elements  pointing  to  parenchymatous  irritation  of  the  kidney. 

I  saw  a  case  in  a  child  six  years  of  age,  in  whom,  after  a  mild 
attack  of  tonsillitis,  there  were  a  few  casts,  blood-cells,  and  a  small 
amount  of  albumin  in  the  urine.  Months  elapsed  before  the  urine 
ceased  to  show  evidences  of  the  nephritis.  In  these  cases  the  albu- 
minuria may  assume  the  so-called  cyclic  character. 

Prognosis. — The  prognosis  of  simple  catarrhal  tonsillitis  is  good, 
recovery  taking  place  in  a  few  days.  On  the  other  hand,  tonsillitis 
is  not  the  simple  entity  formerly  supposed.  In  infants  and  children 
this  is  especially  true.  The  physician  should  be  watchful  for  possi- 
ble complications  and  sequelse,  such  as  otitis,  retropharyngeal  abscess, 
endocarditis,  and  nephritis. 

Diagnosis. — The  diagnosis  of  tonsillitis  is  usually  a  simple  matter. 
If  an  infant  refuses  the  breast  and  the  temperature  is  elevated,  the 
throat  should  be  carefully  inspected.  It  is  good  practice  to  make  a 
bacteriological  culture  with  the  secretionsfrom  the  throat,  even  though 
th(!  appearances  arc  not  diphtheritic  at  the  first  visit  (for  technique, 
see  section  on  Diphtheria). 

Treatment. — The  treatment  of  acute  tonsillitis  is  symptomatic. 
Sponging  with  cold  water  or  water  at  85°  F.  (29.4°  C.)  containing 


DISEASES    OF    TEE    TONSILS.  591 

a  dash  of  alcohol,  will  lower  the  temperature.  A  dose  of  quinine 
should  be  given  twice  daily,  and  if  the  lymph-nodes  at  the  angle  of 
the  jaw  are  enlarged,  cold  applications  should  be  made  externally. 
Sprays  are  not  required  unless  Ihere  is  a  harassing  cough.  Dobell's 
solution  sprayed  three  times  daily  will  relieve  that  symptom.  In 
nursing  infants  the  number  of  feedings  by  the  breast  or  bottle  is 
reduced. 

If  there  is  disturbance  of  the  bowel,  a  teaspoonful  of  castor  oil  or 
grain  -J  (0.03)  of  calomel,  given  twice  daily,  will  empty  the  bowel. 
The  infant  is  then  dieted  on  albumin-water  or  barley-water,  or  a  solu- 
tion of  acorn  cocoa  or  beef-juice  and  barley-water,  until  the  intestinal 
irritation  has  disappeared.  A  return  to  a  milk  diet  may  be  made  as 
soon  as  the  movements  become  normal.  Small  doses  of  ferric  chloride 
have  a  beneficial  effect  on  older  children.  In  mixture  form  it  is  an 
excellent  local  application  to  the  tonsils.  The  custom  of  giving 
potassium  chlorate  in  this  mixture  is  now  generally  abandoned,  the 
drug  being  highly  irritant  to  the  kidneys.  In  nursing  infants  ferric 
chloride  causes  diarrhcea.  For  this  reason  it  should  not  be  admin- 
istered to  them  for  long  periods. 

Herpes  of  the  Tonsils. — Herpes  of  the  tonsils  are  small  vesicular 
formations  seen  on  the  anterior  pillars  of  the  fauces,  just  in  front  of 
the  tonsils.  They  occur  in  a  number  of  slight  febrile  conditions, 
may  accompany  an  angina  of  a  simple  type,  and  are  part  of  the  clin- 
ical picture  of  aphthous  stomatitis.  The  vesicles  burst,  leaving  yel- 
lowish ulcerations  of  the  size  of  a  pin's  head  and  surrounded  by  a 
pink  areola.     They  heal  without  treatment  after  a  few  days. 

Ulceromembranous  Tonsillitis  or  Angina  (Associated  ivith  the 
so-called  Fusiform  Bacillus  of  Vincent). — This  is  a  peculiar  affec- 
tion occurring  in  children.  At  first  one  tonsil  is  affected,  generally 
the  right.  After  a  few  days  the  affection  may  spread  to  the  other 
tonsil.  Most  of  the  cases  I  have  seen  were  unilateral.  In  addition 
to  the  tonsillar  ulcerations,  a  stomatitis  of  an  ulcerative  type  is  often 
present,  and  there  may  be  ulcers  on  the  tongue,  cheeks  and  gums. 

The  size  of  the  tonsillar  ulcer  varies  from  that  of  a  lentil  to  an 
involvement  of  a  greater  part  of  the  tonsil,  the  shape  of  the  ulcer- 
ation being  irregular,  and  its  character  rather  of  a  chancroidal  type. 
It  has  a  worm-eaten  base  with  sharp,  overhanging  edges,  which  may 
be  slightly  raised  above  the  surface  of  the  tonsil.  The  rest  of  the 
tonsil  is  but  very  slightly  inflamed.  The  color  of  the  ulceration  is 
a  yellowish-green  gray,  or  dirty  brown,  and  from  the  first  it  appears 
as  though  the  base  of  the  ulcer  were  covered  by  membrane.  The 
depth  of  the  ulcer  is  quite,  considerable,  varying  from  -|  to  |-  inch. 
The  submaxillary  glands  may  be  enlarged,  or  the  lymph-nodes  com- 


592  DISEASES    OF    THE    BESPIBATOBY    SYSTEM. 

municating  with  tlie  tonsil  at  the  angle  of  the  jaw  may  also  be 
enlarged. 

Etiology, — The  etiology  of  ulceromembranous  tonsillitis  or  angina 
has  been  carefully  worked  out  by  Friihwald,  Vincent,  Lemoine,  Abel, 
and  in  our  own  country  by  Sobel,  Herrman,  and  others.  This  form 
of  tonsillitis  is  caused  by  a  bacillus,  described  more  particularly  by 
Vincent,  and  a  spirillum.  The  bacillus  is  fusiform,  about  twice  as 
long  as  the  dij)htheria  bacillus,  is  pointed  at  both  ends.  Some  of  the 
bacilli  are  bent  into  crescent  shapes.  They  vary  in  size,  some  being 
larger  and  thicker  than  others.  The  spirilla  are  long,  corkscrew- 
like, with  wide  curves.  They  also  vary  in  size,  the  larger  and  thicker 
ones  staining  more  deeply.     The  bacilli  and  spirilla  are  motile. 

Symptoms. — This  affection  can  scarcely  be  classed  as  one  of  the 
more  serious  affections  of  the  tonsil,  although  at  times  of  a  subacute 
chronicity.  The  children  are  brought  to  the  physician  with  a  history 
of  an  ordinary  sore  throat,  and  when  examined  this  ulcer  of  a  deep- 
spread,  pseudomembranous  type  is  found  on  one  or  the  other  tonsil. 
The  appearance  is  as  if  an  irregular  hole  were  punched  out  of  the 
tissue  of  the  tonsil.  There  is  no  spreading  of  membrane,  nothing 
resembling  diphtheria.  There  is  slight  fever,  rarely  higher  than 
103°  or  105°  F.  The  symptoms  at  the  outset  are  so  mild  that  when 
the  patient  is  brought  to  the  physician  the  ulceration  has  taken  place. 
In  those  cases  in  which  there  is  accompanying  stomatitis  on  the 
tongue,  gums,  or  buccal  mucous  membrane,  there  is  also  foetor  of  the 
breath.     In  some  cases  there  may  be  pallor  of  a  distinctly  septic  type. 

Diagnosis. — The  clinical  diagnosis  must  be  made  from  that  of 
diphtheritic  ulcers,  resembling  very  much  what  has  just  been  de- 
scribed. Henoch  and  the  author  have  described  ulcers  of  a  truly 
diphtheritic  character  very  much  resembling  ulceromembranous  an- 
gina. The  only  test  is  that  of  the  culture-tube  or  the  smear.  An 
ordinary  microscopical  smear  stained  from  the  base  of  the  tonsillar 
ulcer  will  reveal  its  true  character  if  of  the  Vincent  type.  If  the 
bacillus  and  spirilla  are  not  evident  at  once,  we  should  make  a  culture 
for  the  diphtheria  bacillus. 

Prognosis. — The  prognosis  is  invariably  good;  although  in  some 
cases  the  course  of  the  disease  is  apt  to  become  subacute,  on  account  of 
the  difficulty  of  reaching  the  base  of  the  ulcer  with  remedies.  Some 
cases  may  last  as  long  as  three  weeks ;  others  recover  within  a  few 
days.     Lemoine  relates  one  case  which  lasted  seventy  days. 

Treatment. — The  treatment  is  much  the  same  as  that  of  an  ordi- 
nary tonsillitis.  The  tincture  of  the  chloride  of  iron  is  given  in 
doses  of  from  3  to  5  minims,  combined  with  glycerin  and  water,  every 
three  hours.  The  base  of  the  ulcer  may  be  touched  daily  either  with 
Lugol's  solution  or  a  10  per  cent,  solution  of  nitrate  of  silver. 


DISEASES    OF   TEE   LABYNX.  593 

DISEASES  OF  THE  LARYNX. 

Acute  Catarrhal  Laryngitis  (Catarrhal  Croup ;  Spasmodic  Croup; 
Spasmodic  Laryngitis;  Pseudocroup). — Etioloi^y.- — Exposure  to  cold 
or  wet  are  predisposing  causes.  Like  the  majority  of  catarrhal  in- 
flammations of  the  respiratory  passages,  acute  catarrhal  laryngitis 
is  due  to  the  invasion  of  bacteria.  It  occurs  as  a  primary  affection, 
and  in  a  modified  form  is  met  with  secondarily  in  measles  and  in- 
fluenza. The  classical  form  of  "  croup  "  is  a  primary  affection,  and 
is  most  common  from  the  second  to  the  fifth  year.  It  is  also  seen  in 
very  young  infants.     One  attack  predisposes  to  others. 

Symptoms. — Catarrhal  croup  or  catarrhal  laryngitis  is  an  affection 
that  causes  much  concern  to  mothers  when  a  first  attack  develops 
without  warning.  During  the  day  the  infant  may  have  had  a  mild 
coryza  with  a  slight  elevation  of  temperature.  Toward  evening  a 
croupy  cough,  accompanied  by  croupy  breathing  or  voice,  suddenly 
develops.  In  some  cases  the  symptoms  remain  mild,  and  only  the 
cough  disturbs  the  patients.  They  breathe  freely,  and  dyspnoea  is 
not  marked.  In  other  cases  the  infant  or  child  goes  to  sleep  free 
from  alarming  symptoms.  Coryza  may  have  been  present  unnoticed 
during  the  day.  During  the  night  the  patient  awakes  with  a  croupy 
cough,  which  rapidly  becomes  worse.  The  breathing  is  noisy  (  croupy  ) 
and  may  be  heard  in  an  adjoining  room.  The  cough  is  especially 
terrifying. 

The  patients  are  restless,  and  cry  during  the  paroxysms  of  cough- 
ing. In  some  cases  they  sit  upright  and  gasp  for  breath.  The  face 
is  pale  and  wet  with  cold  perspiration.  Fever  may  be  slight  or 
marked  and  may  reach  104°  F.  In  the  majority  of  cases  the 
dyspnoea  is  real;  there  is  drawing  inward  of  the  suprasternal  region 
and  the  peri-pneumonic  groove  at  the  epigastrium.  Toward  morn- 
ing the  dyspnoea,  cough,  and  croupy  breathing  subside,  and  the 
patients  fall  asleep,  worn  out  with  the  night's  suffering.  The  next 
day  the  patients  are  apparently  well,  with  the  exception  of  a  slight 
or  marked  croupy  cough,  coryza,  swollen  tonsils,  with  redness  of  the 
pharynx.  For  two  or  three  successive  nights  or  days  there  may  be 
a  repetition  of  the  attack.  This  condition  should  be  differentiated 
from  laryngismus  stridulus.  In  the  latter  there  is  no  fever,  the 
breathing  is  stridulous  during  only  a  short  spasmodic  attack,  and 
there  is  no  croupy  cough.  On  the  other  hand,  pseudocroup  may 
occur  in  children  who  are  rachitic  and  the  subjects  of  laryngismus. 

There  are  forms  of  diphtheritic  laryngitis  without  the  formation 
of  membrane,  which  in  their  symptomatology  are  identical  with  the 
form  of  laryngitis  above  described.  This  is  true  in  very  young 
infants  and  in  children  above  five  years  of  age.     A  culture-test  is  the 

38 


594  DISEASES    OF    THE    JRESFIBATOEY    SYSTEM. 

only  certain  mode  of  differentiating  the  affections.  The  pathological 
condition  giving  rise  to  jDseudocronp  is  believed  to  be  a  swelling  of 
the  mucous  membrane  beneath  the  vocal  cords. 

Diagnosis. — The  diagnosis  is  not  difficnlt  except  in  cases  in  Avhich 
the  croiipy  cough,  breathing,  and  stridor  increase  as  the  day  or  night 
wanes  and  no  relief  comes  to  the  sufferer.  In  other  cases  the  obstruc- 
tion to  the  breathing  in  the  larynx  increases  as  in  truly  membranous 
cases.  Only  a  repeated  culture  will  reveal  the  nature  of  such  an 
affection,  because  one  culture  may  be  liegative  even  in  a  truly  diph- 
theritic case.  In  the  severe  forms  of  "  croup,"  in  the  face  of  increas- 
ing laryngeal  obstruction,  the  interests  of  the  patient  are  best  sub- 
served by  assuming  the  ]3resence  of  a  diphtheritic  process  until  the 
bacteriological  culture  proves  the  contrary  to  be  the  case. 

Prognosis. — The  prognosis  is  good.  I  have  never  met  a  fatal  case 
of  non-diphtheritic  catarrhal  croup.  On  the  other  hand,  many  of 
these  cases  are  due  to  a  grippal  infection.  Such  an  infection  may 
carry  in  its  train  complications,  such  as  bronchopneumonia  or  ear 
affections,  which  may  endanger  the  life  of  the  patient. 

Treatment. — The  patient  is  isolated,  and  placed  under  a  tent  im- 
provised over  the  crib.  The  tent  is  kept  filled  with  steam  generated 
by  any  of  the  devices  for  croup  in  the  market  (croup-kettle)  ;  the 
steam  is  saturated  with  turpentine,  thymol,  or  benzoin.  At  intervals 
of  an  hour  10  grains  of  calomel  are  sublimed  underneath  the  tent 
until  the  croupy  cough  and  breathing  abate.  To  relieve  the  laryngeal 
spasm,  especially  if  there  is  a  temperature,  antipyrin.  in  doses  of  a 
grain  to  every  year  of  the  age,  is  efficient  and  induces  rest  and  sleep. 
Antimony  (/4oo  grain)  combined  with  ipecacuanha  (/loo  grain) 
may  be  given  every  two  hours,  or  20  drops  of  the  syrup  of  ipecac 
every  two  hours  until  emesis  occurs.  Turpeth  mineral  is  given  by 
some  to  induce  vomiting.     I  do  not  use  the  drug. 

If  symptoms  of  progressive  stenosis  set  in,  intubation  is  justified, 
and  in  localities  where  bacteriological  examinations  are  not  feasible, 
diphtheria  antitoxin  should  be  administered,  lest  a  membranous  diph- 
theritic process  be  overlooked.  I  have  seen  cases,  however,  which 
developed  cyanosis  recover  without  intubation.  It  is  questionable 
whether  it  is  justifiable  to  allow  the  patient  to  suffer  when  such  a 
simple  means,  as  the  introduction  of  a  tube  in  the  larynx,  is  feasible. 
The  application  of  counterirritants  to  the  larynx  is  of  questionable 
utility.  The  same  may  be  said  of  the  application  of  heat  or  cold 
externally. 

(Edema  Glottidis  (Submucous  Laryngitis j  Phlegmonous  Laryn- 
gitis).— Definition. — This  is  a  serous  or  seropurulent  infiltration  of 
the  submucous  cellular  tissue  of  the  region  rif  the  upper  larynx,  or 
glottis,  and  the  aryepiglottic  folds. 


DISEASES   OF   THE   LABYNX.  595 

Etiology. — There  are  two  forms — first,  the  simple  serous  infil- 
tration of  the  glottis;  and,  second,  the  inflammatory  infiltration,  the 
so-called  phlegmonous  laryngitis,  in  which  the  submucous  connective 
tissue  is  involved.  The  serous  form  is  secondary  to  and  accompanies 
acute  and  chronic  nephritis,  infectious  diseases,  scarlet  fever,  variola, 
syphilis,  typhoid  fever,  inflammation  or  ulceration  of  the  structures 
adjacent  to  the  larynx,  especially  of  an  erysipelatous  nature. 

The  second  form,  the  phlegmonous  laryngitis,  is  due  to  trauma- 
tism, such  as  the  direct  inhalation  of  steam,  customary  among  chil- 
dren of  the  tenements  when  playing  in  the  kitchen ;  chemicals,  foreign 
bodies,  and  injuries. 

Morbid  Anatomy. — In  the  serous  form  of  oedema  glottidis  the  sub- 
mucous tissue  is  tense,  infiltrated,  pale  or  yellowish  red;  there  is 
swelling  of  the  upper  laryngeal  area.  In  the  phlegmonous  form  the 
mucous  membrane  is  dark  red,  swollen,  covered  with  pus,  and  there 
may  be  ulceration  of  the  mucous  membrane  of  the  larynx  and  vocal 
cords. 

Symptoms. — In  the  forms  accompanying  nephritis  and  the  infec- 
tious diseases,  the  first  symptoms  to  appear  are  those  of  stenosis  of 
the  larynx.  In  the  traumatic  form  of  phlegmonous  laryngitis  with 
consequent  oedema  of  the  glottis,  especially  in  cases  in  which  steam 
has  been  inhaled  by  children,  there  is  pain  in  the  mouth  and  pharynx,, 
dysphagia,  and  dyspnoeic  attacks.  Inspection  shows  the  mucous 
membrane  of  the  mouth  and  pharynx  to  be  inflamed  and  the  tissues 
of  the  epiglottis  swollen;  and  an  inspection  of  the  larynx  reveals 
swelling  of  the  false  vocal  cords  and  narrowing  of  the  rima  glottidis. 

Course.- — The  course  of  the  disease  depends  on  the  nature  of  the 
primary  affection.  The  milder  cases,  especially  those  accompanying 
acute  or  chronic  nephritis,  may  retrograde.  Other  cases,  especially 
the  traumatic,  if  unrelieved,  may  result  in  fatal  suffocation. 

Prognosis. — The  prognosis  must  depend  on  the  prognosis  in  the 
first  form  of  the  primary  affection,  and  in  the  traumatic  and  phleg- 
monous forms  of  laryngitis  the  prognosis  of  the  oedema  glottidis 
depends  on  the  severity  of  the  disease. 

Treatment. — The  treatment  must  consist,  if  a  nephritis  be  present^ 
in  the  treatment  of  the  nephritis,  and  we  must  not  forget  that  intuba- 
tion or  scarification  in  children  is  in  most  cases  ineffectual.  Intuba- 
tion is  apt  to  be  ineffectual  on  account  of  the  additional  traumatism 
caused  by  the  attempts  at  introduction  of  a  tube,  with  consequent 
formation  of  false  pockets.  If  the  symptoms  are  such  that  suffo- 
cation is  imminent,  tracheotomy  offers  the  simplest  and  safest  means 
of  relief. 

In  many  cases  of  oedema  of  the  glottis,  especially  of  the  milder 
type,  a  small  dose  of  the  opiates  will  quiet  the  patient  and  have  a 


696  DISEASES    OF    THE    EESPIRATOBY    SYSTEM. 

tendency  to  relieve  the  apparent  dyspnoea  until  such  time  as  the 
symptoms  of  the  primary  disease  retrograde.  Especially  difficult  of 
treatment  will  be  the  secondary  cases,  with  phlegmonous  disease  in- 
volving structures  adjacent  the  larynx,  such  as  angina  Ludovici.  In 
these  cases  the  swelling  of  the  structures  may  be  so  great  as  to  make 
tracheotomy  a  very  difficult  operation.  Intubation  in  these  cases  is 
scarcely  to  be  thought  of. 

Syphilis  of  the  Larynx.^ — This  affection  is  rare  in  infancy  and 
childhood,  inasmuch  as  it  accompanies  the  later  forms  of  syphilis. 
The  seat  of  election  of  this  disease  is  the  epiglottis,  where  ulcers  and 
condylomata  are  formed.  The  structures  are  thickened,  inflamed, 
covered  with  white,  diffuse  patches,  and  the  same  changes  are  seen 
in  the  interior  of  the  larynx  as  on  the  aryepiglottic  folds.  Cicatrices 
may  form  and  cause  marked  symptoms  of  stenosis.  Ulcers  are  seen 
on  the  back  of  the  tongue  and  on  the  vocal  cords.  Gummatous  infil- 
trations may  form,  ulcerate,  and  lead  to  inflammation  of  the  cartilages 
and  necrosis  of  these  structures,  causing  stenotic  symptoms. 

Diagnosis. — The  diagnosis  depends  on  a  discovery  of  syphilitic 
lesions  elsewhere. 

Prognosis. — The  prognosis  depends  on  how  soon  anti-syphilitic 
treatment  can  be  inaugurated  before  ulceration  and  cicatrization 
results. 

Treatment. — The  treatment  of  this  affection  consists  in  applying 
the  anti-syphilitic  remedies ;  and  when  stenosis  of  the  larynx  occurs 
as  a  result  of  cicatrization  and  contraction  of  the  structures  of  the 
larynx,  intubation  offers  the  most  effective  means  of  relief. 

Tuberculosis  of  the  Larynx. — This  is  very  rare  in  infancy  and 
childhood,  and  is  more  common  toward  the  age  of  puberty.  It  can 
affect  any  part  of  the  larynx,  causing  hoarseness.  It  is  rarely  pri- 
mary, being,  as  a  rule,  secondary  to  tuberculosis  of  the  lungs  or  other 
organs. 

Treatment. — The  treatment  belongs  in  the  realm  of  special  laryn- 
geal work. 

Growths  in  the  Larynx.- — The  most  common  tumors  found  in  the 
larynx  are  papillomata,  granulomata,  and  fibromata.  Malignant 
tumors  are  rare.  Fully  25  per  cent,  of  the  papillomata  are  congen- 
ital, and  manifest  themselves  from  birth  by  symptoms  of  hoarseness 
and  troubled  cough.  A  frequent  case  of  granulomata  and  papillo- 
mata of  the  larynx  is  recurrent  laryngitis  and  oj^erations  upon  the 
larynx,  such  as  intubation  or  tracheotomy. 

Symptoms. ^ — Tumors  of  all  kinds  cause  hoarseness,  accompanied 
by  paroxysms  of  coughing  with  difficulty  of  respiration  due  to  a  cer- 
tain amount  of  stenosis,  varying  according  to  the  size  of  the  tumor. 
Some  of  these  tumors  may  give  rise  to  symptoms  of  suffocation.     The 


DISEASES    OF    TEE    B  BON  CHI.  597 

granulomata  which  follow  tracheotomy  cause  symptoms  of  asphyxia 
after  the  removal  of  the  tube. 

In  addition  to  the  above  symptoms,  there  are  evidences,  in  all 
cases  of  tumor  of  the  larynx,  of  catarrhal  inflammation  of  the  neigh- 
boring structures. 

Treatment. — The  treatment  of  growths  in  the  larynx  belongs  to  the 
realm  of  throat  surgery. 

Foreign  Bodies  in  the  Larynx. — During  play  children  often  aspi- 
rate bodies  of  all  kinds  into  the  larynx,  and  the  symptoms  caused 
depend  very  much  upon  the  size  and  shape  of  the  body  aspirated.  In 
rare  cases  the  body  lodges  in  the  larynx,  and  may  cause  instant  death 
by  suffocation.  Smaller  bodies  lodging  in  the  ventricle  of  the  larynx 
may  cause  attacks  of  dyspnoea,  which  subside  when  the  patient  takes 
the  recumbent  position ;  but  even  these  small  bodies  may  cause  instant 
death  if  they  once  lodge  in  the  rima  glottidis  and  close  the  opening 
of  the  larynx.  Some  of  these  bodies  may  after  a  time  lodge  in  the 
bronchi  and  cause  pneumonia. 

Prognosis. — The  j^rognosis  depends  upon  the  nature  of  the  body 
and  the  possibility  of  dislodging  it. 

Treatment. — If  the  body  is  small,  it  may  sometimes  be  dislodged 
by  standing  the  patient,  as  it  were,  on  the  head.  It  then  emerges 
into  the  larynx  and  is  coughed  out.  If  such  is  not  possible,  it  is  best 
to  locate  the  body  by  means  of  a  radiograph,  and  then  attempt  its 
removal  by  the  branchoscope  and  surgical  means. 

DISEASES  OF  THE  BRONCHI. 

Acute  Simple  Bronchitis. — Bronchitis,  acute  and  simple,  is  an 
affection  of  the  larger  and  medium-sized  bronchi.  In  very  young 
infants  the  disease  is  apt  to  be  very  severe  and  to  attack  the  smallest 
bronchioles;  it  is  then  called  capillary  bronchitis.  A  capillary  bron- 
chitis is  really  a  bronchitis  in  which  there  is  a  certain  amount  of 
peribronchitic  pneumonia.  Acute  bronchitis  may  occur  at  any  period 
of  infancy  or  childhood.  It  is,  however,  less  common  before  the  sixth 
month  of  infancy  than  during  the  period  up  to  the  third  year,  when 
its  frequency  diminishes. 

Etiology. — Bronchitis  may  be  caused  by  an  exposure  to  cold  or 
wet  or  by  traumatism  to  the  mucous  membrane  of  the  air-passages 
through  the  inhalation  of  dust  or  irritating  vapors.  It  occurs  in  the 
acute  infectious  diseases,  such  as  malaria,  scarlet  fever,  measles, 
rotheln,  varicella,  typhus  and  typhoid  fevers,  and  frequently  compli- 
cates pneumonia  of  the  lobular  or  lobar  type.  Rachitis  and  syphilis 
predispose  to  attacks  of  bronchitis.  The  bronchitis  of  heart  disease 
or  nephritis  should  be  regarded  as  of  a  different  class. 


598  DISEASES    OF    THE    BESPIBATOBY    SYSTEM. 

Pathology. — The  bronchi  may  be  filled  with  a  mucous,  serous,  pur- 
ulent, or  mucopurulent  exudate,  which  is  secreted  by  the  epithelium 
of  the  mucous  membrane  and  the  mucous  glands  in  the  wall  of  the 
bronchi.  In  recent  acute  bronchitis  the  mucus  is  quite  abundant. 
In  the  exudate  on  the  mucous  membrane  of  the  bronchi  and  in  the 
lumen,  epithelial  cells,  leucocytes,  and  sometimes  red  blood-cells  are 
found.  The  structure  of  the  mucous  membrane  is  infiltrated  with 
small  round  cells  to  a  greater  or  less  degree.  In  some  places  the 
epithelial  lining  of  the  bronchi  may  be  raised  by  extidate ;  in  others 
there  may  be  loss  of  the  superficial  epithelium.  If  the  bronchitis 
lasts  any  length  of  time,  there  may  be  atrophy  of  the  structures  of  the 
mucous  membrane.  In  the  severer  forms  of  bronchitis  which  afi^ect 
the  smaller  bronchi  the  peribronchitic  connective  tissue  is  infiltrated 
with  small  round  cells.  In  these  cases  there  is  an  inflammatory 
exudate  in  the  surrounding  alveoli  of  the  lung.  There  is  then  peri- 
bronchitis or  bronchopneumonia. 

Symptoms. — In  some  cases  the  infant  or  child  suffering  from  acute 
bronchitis  will  have  a  simple  angina  as  an  initial  symptom.  There 
is  mild  redness  of  the  fauces  with  a  slight  rise  of  temperature  which 
may  last  a  day  or  more.  The  cough  which  was  present  at  first  per- 
sists, and  there  may  be  slight  disturbance  of  the  bowels,  the  move- 
ments are  green  and  contain  large  curds  of  undigested  matter. 

The  cough  may  in  aggravated  cases  give  rise  to  occasional  attacks 
of  vomiting,  especially  immediately  after  nursing;  at  other  times  the 
coughing  spells  may  cause  the  patient  to  <^ry.  There  is  evidently 
pain,  especially  in  the  cases  of  bronchitis  affecting  the  larger  bronchi. 
The  infant  sometimes  suffers  from  gTeat  difficulty  in  expelling  the 
accumulated  secretion.  The  attacks  of  coughing  closely  resemble 
those  seen  in  old  people  who  suffer  from  bronchitis.  In  many  cases 
the  infant  or  child  is  quite  comfortable  in  the  intervals  between  the 
coughing  spells.  In  others  the  respirations  are  increased,  and  there 
may  for  some  days  be  a  slight  evening  rise  of  temperature,  the 
patient  showing  signs  of  being  seriously  ill.  In  very  young  infants 
who  are  rachitic  there  may  be  a  distinct  drawing  in  of  the  sides  of 
the  chest  and  of  the  peripneumonic  groove  at  each  respiration.  In 
cases  of  severe  involvement  of  the  smaller  bronchi,  there  may  be 
slight  cyanosis  of  the  lips  and  pallor  of  the  surface. 

In  the  severer  forms  of  bronchitis,  especially  of  the  grippal 
variety,  there  is  a  febrile  temperature  for  several  days.  It  may  rise  to 
102^-103=  F.  (38.8°-39.4°  C),  or  even  higher,  with  a  correspond- 
ing increase  in  the  number  of  respirations  and  the  pulse-rate.  In 
weak  and  very  young  infants  there  may  be  little  or  no  cough.  The 
infant  lies  in  a  soporose  state,  does  not  nurse  well  or  refuses  the 
breast.     Older  children  may  run  about  and  play  while  suffering  from 


DISEASES    OF   THE   BBONCEI.  599 

bronchial  trouble;  severe  bronchial  disturbance  may  appear  to  have 
little  effect  on  the  general  health.  Expectoration  is  exceptional;  a 
frothy  mucus  collects  about  the  lips  of  young  infants  after  an  attack 
of  coughing. 

In  older  children  it  may  be  very  difficult  to  collect  sputum,  even 
if  they  are  old  enough  to  understand  the  necessity  of  expectorating. 
The  conclusion  has  been  that  children  swallow  the  sputum ;  it  is  more 
rational  to  suppose  that  the  efforts  at  coughing  are  not  equal  to  rais- 
ing any  considerable  quantity  of  secretion  or  that  the  amount  of 
secretion  in  bronchitis  is  not  so  great  as  has  been  generally  supposed. 
In  many  cases  the  cough  is  severer  at  night  than  during  the  day,  but 
children  cough  and  fall  asleep  immediately  afterward,  and  therefore 
do  not  lose  much  rest.  I  have  never  met  with  a  simple  acute  bron- 
chitis ushered  in  by  a  chill  or  convulsion.  I  have,  however,  seen 
severe  forms  of  bronchitis  cause  petechial  extravasations  on  the  skin, 
similar  to  those  seen  in  pertussis.  The  petechise  are  apt  to  occur 
about  the  forehead  and  eyes  of  very  weak  infants. 

Physical  Signs. — In  mild  cases  the  number  of  respirations  may  be 
slightly  above  the  normal ;  in  severer  cases  there  are  signs  of  dyspnoea 
and  the  respirations  are  increased  in  number.  In  very  severe  forms 
the  peripneumonic  groove  may  be  drawn  inward  with  each  respira- 
tory act.  In  capillary  bronchitis  the  lips  may  show  some  cyanosis, 
the  surface  may  be  pale,  and  the  finger-tips  slightly  cyanosed. 

Palpation. — If  the  palms  of  the  hands  are  placed  on  the  anterior 
and  posterior  chest  wall,  the  so-called  rhonchal  fremitus  may  be  de- 
tected. The  vibrations  caused  by  accumulated  secretion  in  the  large 
and  small  bronchi  give  a  sensation  resembling  that  felt  in  stroking  a 
purring  cat. 

Percussion. — In  simple  acute  bronchitis,  percussion  may  elicit 
nothing  abnormal.  If  infants  have  suffered  from  repeated  attacks 
of  bronchitis,  the  note  may,  owing  to  a  slight  emphysema,  be  hyper- 
resonant  or  vesiculotympanitic.  In  severe  forms  of  capillary  bron- 
chitis there  may  be  areas  of  peribronchitic  pneumonia  or  broncho- 
pneumonia, over  which  careful  percussion  will  detect  slight  dulness 
with  a  resonant  note. 

Auscultation. — In  a  number  of  cases,  bronchitis  at  the  outset, 
gives  on  auscultation  nothing  but  a  rude  respiratory  murmur  which 
is  more  markedly  puerile  than  normal.  As  the  secretion  accumu- 
lates there  will  be  sonorous,  sibilant,  and  crepitant  rales,  and  also 
sonorous  breathing.  In  the  form  called  capillary  bronchitis,  with 
the  subcrepitant  rales  there  will  be  rales  of  much  finer  quality,  resem- 
bling crepitant  rales.  The  latter,  which  are  unmistakable,  are  heard 
on  inspiration,  and  appear  to  indicate  areas  of  peribronchitic  pneu- 
monia.    In  newly  born  and  weakly  infants  there  are,  in  this  form 


600  DISEASES    OF    IRE    EESPIBATOEY    SYSTEM. 

of  bronchitis,  areas  in  whicli  the  air  is  not  heard  to  enter  the  lungs 
(atelectasis). 

Treatment. — The  treatment  of  simple  acute  bronchitis  should  be 
supporting  and  expectant.  If  the  cough  is  harassing,  a  mild  opiate 
mixture  in  combination  with  a  small  quantity  of  ipecac  may  be 
given.     The  following  prescription  has  been  found  useful : 

J^     Tinet.  opii  camph 5j  (4.0). 

Syr.  ipecacuanhee n\,  xxxij  (2.0). 

Syr.   tolutani ^ij  (60.0). 

Sig.     Teaspoonful  every  three  hours. 

The  patients  are  allowed  to  be  in  the  open  air  in  fine  weather,  and 
the  room  should  be  well  ventilated  at  night.  In  cases  in  which  there 
is  great  relaxation  of  the  mucous  membranes,  a  dose  of  strychninse 
sulph.,  grain  %oo  (0.0003),  may  be  given  three  or  four  times  daily. 
The  child  is  kept  warmly  clad,  and  wool  is  worn  next  the  skin. 
Douching  with  cold  water  is  to  be  avoided  in  acute  cases.  The  oil- 
silk  jacket  may  be  worn,  but  it  has  no  superiority  to  warm  clothing. 
Applications  of  oil  to  the  chest  are  of  no  value.  The  drugs  of  the 
coal-tar  series  (antipyrin  or  phenacetin)  should  not  be  used,  except 
that  one  dose  may  be  given  at  the  very  outset  to  relieve  restlessness 
or  headache.  The  bowels  are  relieved  by  means  of  calomel  or  a  saline 
cathartic. 

In  the  subacute  stage,  syrup  of  ferric  iodide  may  be  given  as  a 
tonic  for  the  mucous  membrane.  In  rachitic  infants  and  children, 
cod-liver  oil  is  indicated. 

The  treatment  of  so-called  capillary  bronchitis  approaches  very 
closely  that  of  bronchopneumonia.  The  heart  should  be  supported. 
Digitalis  in  the  form  of  tincture  is  the  most  useful  remedy.  Strych- 
nine, caffeine,  camphor,  and  musk  in  form  of  powder,  all  have  here 
their  legitimate  sphere. 

The  temperature,  as  a  rule,  needs  no  treatment.  With  older  chil- 
dren, if  the  secretion  is  very  profuse,  carbonate  of  guaiacol  is  exceed- 
ingly useful  and  gives  much  relief. 

Fibrinous  or  Plastic  Bronchitis. — This  is  a  form  of  bronchitis  in 
which  membranous  masses  or  fibrinous  exudate  are  coughed  up  at 
intervals.  These  masses  may  have  the  form  of  the  bronchi,  or  may 
consist  of  shreds  or  bands  of  membrane. 

Etiology. — Bronchitis  of  this  form  complicates  diphtheria  and 
pneumonia,  and  also  occurs  in  the  acute  infectious  diseases — measles, 
scarlet  fever,  tuberculosis,  erysipelas,  typhus  and  typhoid  fevers.  It 
is  found  in  diseases  of  the  heart  and  lungs,  and  may  result  from 
traumatism  through  the  inhalation  of  jDoisonons  gases.  The  above 
are  the  secondary  forms;  the  primary  form  of  fibrinous  bronchitis  is 
obscure  in  its  etiology,  and  is  rare  in  infancy  and  childhood. 


DISEASES    OF    THE    BBONCEI.  601 

Morbid  Anatomy. — The  casts  which  are  coiiglied  up  are  cylindrical 
in  shape  and  branched  in  the  form  of  the  larger  and  smaller  bronchi. 
The  larger  ones  may  be  hollow  and  cylindrical,  while  the  smaller 
ramifications  may  be  solid  or  thready.  In  other  cases  the  whole  cast 
is  solid ;  small  air-bubbles  may  be  confined  in  the  fibrinous  cylinders. 
The  casts  may  be  10-12  cm.  in  length,  the  extremities  being  nodular, 
thready,  or  flat.  Under  the  microscope  they  are  seen  to  be  formed  in 
layers ;  in  the  centre  of  the  oldest  layers  are  found  epithelium  of  the 
bronchi,  leucocytes,  and  bacteria.  Spirals  formed  of  fibrin  are  occa- 
sionally found  in  the  expectorated  masses,  especially  in  the  diph- 
theritic, pneumonic,  and  the  so-called  idiopathic  cases. 

Symptoms. — Attachs  of  Dyspnoea. — This  form  of  bronchitis  is 
characterized  by  attacks  of  dyspnoea  and  coughing.  During  the 
attacks  clots  of  purulent  fibrinous  masses  are  expectorated,  some- 
times with  a  slight  amount  of  blood.  In  spite  of  the  expectoration 
of  blood  there  are  no  signs  of  tuberculosis.  The  presence  of  blood 
is  probably  caused  by  the  detachment  of  the  membranous  casts  from 
the  walls  of  the  bronchi.  The  expectorated  masses  may  contain 
asthma  crystals.  In  the  intervals  between  the  attacks,  there  may  be 
symptoms  of  an  ordinary  bronchitis  with  mucopurulent  expectora- 
tion, or  there  may  be  absolute  freedom  from  symptoms. 

Cough. — The  cough,  which  is  present  during  the  attacks,  may  be 
accompanied  by  a  snarling  or  fluttering  sound. 

Cyanosis. — Cyanosis  may  be  present  during  the  attack  to  a  marked 
degree  or  may  be  absent. 

Fever. — Fever  is  present  in  the  acute  form,  but  has  no  special 
characteristics. 

Splenic  Tumor. — Splenic  tumor  may  be  present. 

Physical  Signs. — The  physical  signs  of  bronchitis  may  be  present 
with  rales  of  all  kinds.  If  the  membranous  masses  hang  detached  in 
the  bronchi,  a  snarling  or  flapping  sound  may  be  heard  on  auscultation. 

The  general  condition  of  patients  in  the  intervals  and  during  the 
attacks  varies  greatly.     In  some  cases  it  is  fairly  good. 

Complications. — A  tuberculous  bronchitis  or  pneumonia  may  be  a 
complicating  condition. 

Diagnosis. — The  diagnosis  is  made  from  the  presence  of  the  fibrin- 
ous casts. 

Treatment. — The  treatment  has  thus  far  been  very  unsatisfactory ; 
mercury,  and  also  inhalations  and  sprays  of  all  kinds  have  been  tried 
in  the  acute  cases.  Iodide  of  potassium  is  of  value  in  the  intervals. 
If  diphtheria  is  present,  the  antitoxin  is  given. 

Emphysema  and  Chronic  Bronchitis  of  the  Lungs. — Frequency. 
— Emphysema  is  a  condition  frequently  seen  postmortem  in  the  lungs 
of  infants  and  children  (Steffen).     'No  disease  of  the  lungs  runs  its 


602  DISEASES    OF    THE    BESPIBATOBY    SYSTEM. 

course  without  causing  some  emphysema.  The  condition  is  much 
more  common  in  children  than  in  adults,  because  it  is  favored  by  the 
peculiar  structure  of  the  lung  in  early  life.  Most  of  the  forms  of 
emphysema  of  the  lungs  of  infants  and  children  retrograde,  allowing 
the  lung  to  return  to  its  normal  state.  Otherwise  emphysema  would 
be  more  common  in  adult  life  than  it  is.  Clinically,  emphysema 
combined  with  various  forms  of  pulmonary  disease,  especially  bron- 
chitis, is  very  common  in  infants  and  children.  My  experience  in  this 
respect  confirms  that  of  Steffen  and  Osier.  It  seems  to  be  common 
to  certain  classes  of  children,  especially  those  of  rachitic  tendencies. 

Morbid  Anatomy. — Steffen  has  made  a  very  careful  study  of  the 
pathological  condition  in  emphysema  of  the  lungs  of  infants  and 
children.  The  thorax  has  not  the  typical  barrel  shape  seen  in  the 
adult,  and  occasionally  found  in  older  children.  In  younger  chil- 
dren, especially  those  with  rachitis,  the  sides  of  the  lower  portion 
of  the  thorax  are  incurved;  the  upper  part  of  the  thorax  in  front 
underneath  the  clavicles  may  be  full  and  prominent.  On  opening 
the  chest,  the  lungs  are  found  to  be  inflated,  to  retain  their  form,  and 
to  show  along  the  situation  of  the  ribs  a  series  of  indentations  due 
to  pressure.  The  depressed  portions  may  be  denser  than  those  raised, 
and  show  areas  of  circumscribed  persistent  pneumonia.  In  vesicular 
emphysema,  air-vesicles  may  rupture  into  one  another,  giving  rise  to 
large  sac-like  formations  which  communicate  with  a  bronchus.  Some 
of  the  air-vesicles  may  rupture  into  the  subpleural  tissue.  Vesicular 
emphysema  rarely  involves  a  whole  lung  or  both  lungs,  but  is  localized 
to  certain  areas,  such  as  the  apices,  anterior  borders,  or  the  lingula. 

The  emphysematous  areas  are  whitish,  yellowish  white,  or  red- 
dish yellow,  the  color  varying  with  the  amount  of  blood  contained. 
They  are  raised  above  the  surface,  are  elastic  and  velvety  to  the  touch, 
and  crepitate  with  the  air  contained.  In  children,  in  contrast  to  the 
condition  in  the  adult,  the  heart  is  rarely  dilated,  and  the  liver  and 
kidneys  rarely  affected.  This  is  due  to  the  temporary  nature  of  the 
process.  Bronchitis,  trachitis,  and  laryngitis  may  exist  as  primary 
or  secondary  conditions.  It  is  not  possible  to  consider  emphysema 
in  infants  and  children  as  an  isolated  condition.  Since  it  is  most 
frequently  seen  in  pronounced  bronchial  affections,  it  will  be  con- 
venient to  consider  it  in  connection  with  bronchitis. 

Symptoms. — Some  infants  and  children  suffer  from  a  chronic 
catarrhal  bronchitis  which  is  more  or  less  present  at  all  times,  and 
which  may  be  interrupted  by  attacks  of  acute  bronchitis.  Infants 
and  children  thus  affected  are  more  or  less  rachitic;  some  have 
lymphatism  in  the  form  of  chronic  hypertrophic  rhinitis  and  also 
adenoids  or  enlarged  tonsils.  In  the  intervals  between  the  attacks  of 
acute  bronchitis;  the  patients  do  not  seem  to  suffer  much  constitu- 


DISEASES    OF    TEE   BBONCHI. 


603 


tional  disturbance.  There  is  no  fever,  and  no  change  in  the  respira- 
tion except  that  it  assumes  a  noisy  character.  There  is  a  cough 
which  comes  on  at  intervals,  especially  at  night.  The  infants  are 
pale,  with  rather  flabby  muscles,  and  may  be  fat,  but  impress  the 
physician  as  being  below  the  normal  in  point  of  strength. 

Physical  Signs. — If  the  bronchitis  has  persisted  a  long  time,  the 
upper  part  of  the  chest  is,  even  in  infants  under  the  age  of  twelve 
months,  abnormally  full.     The  upper  costosternal  region  is  high  and 

Fig.  120. 


Emphj'sema  of  the  lung  in  a  boy  eight  years   of  age  ;   diminished  cardiac  area   of 

relative  dulness. 


the  intercostal  spaces  are  filled  out.  In  milder  cases  there  are  no 
signs  to  be  detected  on  inspection. 

Palpation. — There  is  distinct  rhonchal  fremitus  felt  anteriorly 
and  posteriorly. 

Percussio7i. — If  there  have  been  a  number  of  acute  attacks,  there 
will  be  emphysema  of  a  vesicular  type,  giving  a  hyper-resonant  note. 
In  pronounced  rachitis  the  hyper-resonance  is  apt  to  be  marked.  The 
area  of  relative  cardiac  dulness  in  older  children  is  much  diminished 
(Fig.  120). 

Auscultation. — Voice-sounds  are  normal.  The  breathing  is  rude 
or  sonorous.  The  respiratory  murmur  may  be  prolonged.  There 
are  sonorous,  mucous,  and  subcrepitant  rales. 


604  DISEASES    OF    THE    SESPISATOEY    SYSTEM. 

A  second  set  of  eases  of  chronic  bronchitis  comprises  those  in 
which  a  condition  of  prononnced  emphysema  of  a  vesicular  character 
is  present,  and  in  which  there  are  distinct  attacks  of  dyspnoea  or 
asthma.  These  cases  must  be  differentiated  from  the  purely  neurotic 
cases  of  spasmodic  asthma.  The  latter  condition  is  rare  in  children, 
and  is  not  accompanied  by  chronic  catarrhal  bronchitis.  The  history 
of  these  cases  is  one  of  repeated  attacks  of  acute  bronchitis.  The 
lung  may  in  the  interval  be  wholly  free  from  signs  of  bronchitis.  A 
condition  of  this  kind  is  apt  to  be  left  in  the  lung  after  a  severe  attack 
of  pertussis.  The  infants  or  children  may  bear  the  marks  of  rachitis, 
and  are  usually  anaemic.  In  the  intervals  between  the  acute  attacks 
of  asthma,  the  general  condition  is  good.  There  is  no  fever ;  there 
may  be  dyspnoea  on  exertion.  An  attack  of  asthma  is  precipitated 
by  exposure  to  cold  or  wet.  During  the  attacks  infants  and  children 
do  not  suifer  much,  although  they  show  signs  of  marked  dyspnoea. 
There  are  none  of  the  typical  signs  of  an  attack  of  spasmodic  asthma 
in  the  adult.  An  infant  showing  very  marked  dyspnoea  will  play  in 
the  arms  of  the  mother.  The  lips  may  be  cyanosed  and  the  surface 
pale  and  cool.  There  is  no  temperature.  There  is  in  these  subjects 
a  tendency  to  develop  a  cough  of  a  laryngeal  type  on  the  least  expo- 
sure. Examination  of  the  chest  shows  nothing  except  a  prolonged 
rude  respiratory  murmur,  while  percnssionwill  give  a  hyper-resonant 
note  over  the  whole  chest.  Suddenly  an  attack  of  so-called  asthma 
will  develop,  with  all  the  physical  signs  given  below.  The  onset  of 
the  attack  is  sometimes  signalized  by  a  slight  rise  of  temperature, 
100°  to  101°  F.  (37.7°  to  38.3°  C),  and  an  increase  in  the  number 
of  respirations,  32  to  36  per  minute.  On  examination,  the  chest 
shows  all  the  signs  of  an  acute  attack  of  bronchitic  asthma.  An 
attack  lasts  for  from  a  few  hours  to  a  few  days.  The  children  usually 
play  about  and  seem  little  disturbed  by  their  condition. 

During-  an  Attack  of  Spasmodic  Dyspnoea. — Inspection. — - 
Inspection  shows  a  drawing  inward  of  the  supersternal  structures  on 
inspiration,  and  a  depression  of  the  peripneumonic  groove.  The 
upper  part  of  the  chest  is  high  and  filled  out,  and  moves  little  on 
inspiration  and  expiration.  The  lower  part  of  the  thorax  has  also 
little  movement.  In  rachitic  children,  there  is  not  only  drawing 
inward  of  the  lower  part  of  the  thorax,  but  also  a  distinct  incurvation 
of  the  lower  ribs,  caused  by  the  repeated  attacks  of  dyspnoea.  The 
chest  is  moved  as  a  whole.  In  children  of  seven  or  eight  years  the 
dyspnoea  may  be  severe  in  the  absence  of  cyanosis.  These  patients 
apparently  suffer  more  than  infants. 

In  older  children,  the  chest  has  the  typical  barrel  shape  seen  in 
the  adult  sufferer  from  asthma  (Fig,  120).  In  some  cases  there  is 
a  drawing  inward  of  the  intercostal  spaces  on  inspiration.  Some 
cases  have  a  constant  cough  and  frothy  expectoration. 


DISEASES    OF    THE    BliONCHI. 


605 


Palpation. — Palpation  gives  rhonchal  fremitus  and  faint  cardiac 
impulse. 

Peixussion.  —  Percussion  gives  a  ve^iculotympanitic  or  hyper- 
resonant  note  over  the  whole  chest,  and  cardiac  dulness  obscured  and 
diminished  by  the  emphysematous  lung. 

Auscultation. — Auscultation  gives  a  prolonged  expiratory  mur- 
mur and  sibilant  and  sonorous  rales.     Heart-sounds  are  feeble. 

Betweeist  Attacks  of  Dyspncea. — Between  the  attacks  of  dysp- 
noea the  chest  retains  the  above  forms.     There  may  be  a  slight  con- 


FiG.   121. 


Emphysema  of  lung  :  boy  eight  years  of  age  ;   barrel-shaped  thorax. 

as   Fig.    120. 


Same  patient 


stant  dyspnoea  or  none  at  all.  The  patient  feels  quite  well,  and  does 
not  complain  of  the  dyspnoea.     The  heart  apex-impulse  is  diffused. 

Palpation  gives  little  or  no  rhonchal  fremitus. 

Percussion. — Percussion  shows  a  note  hyper-resonant,  but  not  as 
markedly  so  as  during  the  paroxysm  of  dyspnoea.  Cardiac  relative 
dulness  is  obscured  by  the  presence  of  emphysema. 

Auscultation. — In  older  children  the  expiratory  murmur  may  be 
prolonged  or  inaudible.  There  are  signs  of  residual  bronchitis,  sibi- 
lant, sonorous,  and  subcrepitant  rales,  and  in  young  infants,  large 
mucous  rales.  The  signs  may  be  hardly  noticeable  or  heard  only  in 
certain  portions  of  the  chest. 


606  DISEASES    OF    THE    BESPIEATOBT    SYSTEM. 

Prognosis. — In  both  forms  of  chronic  bronchitis  the  prognosis 
as  to  life  is  very  good.  The  chances  of  nltimate  restoration  of  the 
lung  to  the  normal  condition  depend  much  on  the  mode  of  living 
and  the  power  of  the  individual  to  outgrow  the  conditions  of  rachitis 
and  lymphatism  which  exist  in  many  of  these  cases.  Many  of  these 
forms  of  chronic  bronchitis  disappear  ultimately ;  the  emphysematous 
form  may  persist  into  adult  life. 

Treatment.- — The  treatment  of  chronic  bronchitis  is  directed  to- 
ward improving  the  general  tone  of  the  economy  and  also  the  muscu- 
lature of  the  heart.  It  must  be  assumed  that  in  these  cases  the  heart 
as  well  as  the  other  organs  suffers  from  a  lack  of  power,  to  which  may 
be  attributed  the  relaxed  condition  of  the  circulation  in  the  mucous 
membrane  of  the  bronchi.  Life  in  the  open  air,  hydriatic  treatment, 
and  drugs,  such  as  strychnine,  will  have  beneficial  effects.  The 
mucous  membranes  are  benefited  by  preparations  of  iron  which  con- 
tain iodine  (syrup  of  the  iodide  of  iron),  freshly  j^repared  and  given 
in  large  doses.  Cod-liver  oil  is  an  excellent  tonic  in  winter.  The 
skin  should  be  protected  from  extremes  of  heat  and  cold  by  suitable 
underwear.  Moderate  participation  in  sports  in  the  open  air  im- 
proves the  action  of  the  heart.  Running  and  gymnastics  are  to  be 
preferred  to  bicycle-riding. 

A  dry  climate  will  do  much  toward  improving  the  condition  of 
the  lung.  During  the  attack  of  dyspnoea,  iodide  of  potassium  will 
be  of  service  in  alleviating  the  symptoms.  This  is  the  most  useful 
remedy.  It  is  also  of  great  benefit  when  given  in  the  intervals 
between  the  attacks.  The  other  drugs  used  with  adults  are  not  indi- 
cated. An  exception  is  Fowler's  solution,  which  is  an  exceedingly 
useful  remedy  in  moderate  dosage  in  the  intervals  of  the  attacks,  to 
be  given,  over  a  prolonged  period.  I  have  seen  good  results  follow 
the  use  of  digitalis  in  the  form  of  the  tincture,  in  combination  with 
the  iodide  of  potassium.  The  heart  is  thus  greatly  aided  in  improv- 
ing the  circulatory  conditions  in  the  emphysematous  lung.  Rest 
from  exertion  is  indicated  during  the  attack,  but  patients  may  be  kept 
out  of  doors  if  they  will  remain  quiet.  Codeine  is  most  useful  in 
allaying  the  cough.  The  administration  of  a  large  dose  once  or  twice 
daily  is  preferable  to  giving  small  doses  at  shorter  intervals. 

Bronchiectasis,  Including  Putrid  Bronchitis. — Bronchiectasis,  or 
dilatation  of  the  bronchi,  is  not  a  very  uncommon  condition  in  infants 
and  children.  In  most  pulmonary  disorders  in  infants  and  children, 
very  slight  dilatation  of  the  bronchi  may  result.  These  have  no  clin- 
ical significance,  and  retrograde  to  the  normal  state  in  time.  The 
marked  dilatations  are  the  congenital  bronchiectasis  and  the  acquired 
or  inflammatory  form. 

Varieties. — Congenital. — This  is  a  condition  in  the  newly  born 


DISEASES    OF    THE    BBONCEI.  607 

infant  which  has  been  known  to  persist  into  adult  life  (Grawitz, 
Welch,  Kessler,  Frankel).  It  generally  affects  one  lung  or  a  part  of 
one  lung.  The  lung  structure  is  replaced  by  cystic  formations  which 
contain  a  serous  fluid,  in  which  are  found  nuclei  and  ciliated  epithe- 
lium. The  main  bronchi  may  be  cystic,  with  a  system  of  minor  cavi- 
ties separated  from  the  main  cavity  by  a  series  of  septa.  In  this  way 
numerous  recesses  are  formed.  The  walls  of  the  cysts  may  be  cov- 
ered with  several  layers  of  cuboidal  epithelium.  jSTo  distinctive 
symptomatology  has  been  reported  in  these  cases. 

Etiology. — Whatever  the  exact  cause  of  a  bronchiectasis,  there  is 
certainly  a  diminished  resistance  of  the  walls  of  the  bronchus  to  the 
inroads  of  inflammatory  processes.  In  order  to  explain  the  imme- 
diate formation  of  these  cavities,  Hoffman  has  assumed  that  a  stenosis 
of  the  lumen  of  the  bronchus  (as  shown  by  Frankel  and  Lichtheim), 
must  be  produced  by  inflammatory  processes  and  that  under  these 
conditions  the  repeated  attacks  of  coughing  produce  dilatation.  Such 
stenosis  may  have  its  origin  in  a  peribronchitis  or  a  pneumonia  caus- 
ing thickening  of  the  wall  of  the  bronchus.  Pleurisy,  chronic  pneu- 
monia, croupous  or  catarrhal,  syphilis,  and  foreign  bodies  lodged  in 
the  lumen  of  the  bronchi  may  be  the  direct  cause  of  a  bronchiectasis. 
Finally,  there  are  the  forms  of  bronchiectasis  called  primary,  because 
their  etiology  has  not  as  yet  been  explained. 

Infiamrnatory.- — The  inflammatory  form  of  bronchiectasis  may 
be  sacculated,  spindle-shaped,  or  cylindrical  (vicarious).  The  cylin- 
drical bronchiectasis  shows  the  bronchus  dilated  into  a  cylindrical 
form.  This  dilatation  may  merge  gradually  or  abruptly  into  the 
main  bronchus.  The  spindle-shaped  bronchiectasis  is  only  a  form 
of  the  cylindrical  variety. 

Pathology. — The  sacculated  bronchiectasis  is  the  most  common 
variety,  and  clinically  the  most  important.  It  usually  affects  the 
smaller  bronchi.  A  sac  communicates  with  the  trachea,  and  has  no 
other  outlet.  The  entry  into  the  sac  may  be  by  way  of  a  normal, 
a  dilated,  or  a  stenosed  bronchus.  If  the  infundibula  are  dilated, 
small  cavities  are  formed  (pulmonary  vacuoles).  In  other  cases  the 
afferent  bronchus  may  be  obliterated,  and  the  cystic  formations  are 
then  of  varying  size.  The  wall  of  the  bronchus  leading  to  a  cavity 
of  this  nature  is  in  a  state  of  catarrh,  and  may  be  thickened  or  infil- 
trated. The  epithelium  may  be  present  only  in  spots.  The  infiltra- 
tion may  affect  the  walls  of  the  alveolar  septa.  The  mucous  mem- 
brane may  after  a  time  become  atrophic.  The  cartilages  of  the 
bronchi  may  also  become  atrophic  and  be  replaced  by  connective 
tissue  which  may  extend  for  varying  distances  into  the  lung  sub- 
stance, forming  trabeculse.  The  epithelium  of  the  bronchi  may  be 
replaced  by  pavement  epithelium.     The  mucous  membrane  becomes 


608 


DISEASES    OF    THE    BESPIBATOEY    SYSTEM. 


thickened  or  is  replaced  by  polypoid  masses.  The  bloodvessels  finally 
become  dilated.  There  may  thus  be  formed  throughout  the  lung 
small  aneurismal  dilatations  of  the  bloodvessels.  The  remaining 
lung  tissue  may  be  emphysematous  or  sclerosed  as  above.  The  pleura 
may  be  thickened. 

Symptomatology. — The  symptoms  include  expectoration,  a  cough, 
dyspnoea,  deformity  of  the  chest,  and  fever. 

Expectoration.- — There  is  expectoration  of  a  mucopurulent  char- 
acter, which  cannot  be  differentiated  from  the  expectoration  of  some 
forms  of  bronchitis.  In  other  cases,  large  quantities  of  a  fetid,  puru- 
lent material  are  expectorated.  This  expectoration  may  at  times  be 
mingled  with  streaks  of  blood,  or  there  may  be  a  distinct  hemorrhage, 


Fig.  122. 


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WEIGHT       34  LBp.                                                                                    32  LBS. 

Bronchiectasis  ;  febrile  and  afebrile  periods.     Boy,  seven  years  of  age. 

resulting  in  some  cases  in  a  fatal  haemoptysis.  Sometimes  the 
sputum  is  profuse,  exceedingly  fetid,  fluid,  and  purulent,  and  will  on 
standing  separate  into  a  serous  and  a  purulent  portion. 

Cough. — The  cough  may  be  occasional  or,  if  the  bronchiectasis 
exists  in  the  apex  of  the  lung,  incessant.  It  is  apt  to  be  more  marked 
in  the  morning,  and  may  at  that  time  be  accompanied  by  the  expecto- 
ration of  the  sputum  accumulated  during  the  night.  At  other  times, 
change  of  position  will  cause  paroxysms  of  coughing  and  the  evacua- 
tion of  large  quantities  of  sputum. 

Dyspnoea. — Dyspnoea  is  present  not  only  during  the  paroxysms  of 
coughing,  but  also  in  the  intervals,  especially  if  there  are  extensive 
secondary  changes  in  the  lungs  or  pleura. 

Fever. — Fever  of  a  hectic  character  is  very  likely  to  be  present  at 
times  when  the  secretion  in  the  lung  accumulates.     The  temperature 


DISEASES    OF    THE    BRONCHI.  609 

will  then  rise  a  degree  or  more,  but  subside  when  the  lung  is  again 
cleared  of  bronchiectatic  accumulations  (Fig.  122).  These  rises  of 
temperature  may  simulate  those  in  the  course  of  empyema  or  tuber- 
culosis. If  abscess  of  the  liver  or  kidney,  endocarditis,  or  pneumonia 
occurs  as  a  complication,  the  rise  of  temperature  will  be  more  marked. 

Deformity. — Deformity  of  the  chest  is  apt  to  occur  in  severe  cases 
in  which  there  is  emphysema  of  the  lung  or  j)leuritis.  In  3  of  my 
cases  there  have  been  deformities  of  the  finger  and  toes.  These,  the 
so-called  clubbed  fingers,  are  not  characteristic  of  bronchiectasis,  since 
they  are  found  in  congenital  cardiac  disease  and  tuberculosis  of  the 
lung.  There  is  pain  as  a  result  of  existent  pleurisy.  Albuminuria 
may  be  present  as  a  result  of  amyloid  changes.  Hsemoptyosis  is 
generally  a  late  symptom,  but  is  not  very  common.  Diarrhoea  of  a 
septic  nature  may  occur  in  the  course  of  the  disease. 

Complications. — Complications  include  decomposition  of  the  bron- 
chiectatic accumulations,  pneumonia,  gangrene  of  the  lung,  emphy- 
sema, pleurisy,  empyema,  perforation  of  the  lung,  laryngeal  disease, 
kidney  and  heart  disease,  liver  abscess,  abscess  of  the  brain,  and 
finally  amyloid  degeneration  of  the  liver,  spleen,  and  kidneys. 

Diagnosis. — A  positive  diagnosis  of  bronchiectasis  cannot  always 
be  made,  especially  in  those  cases  in  which  there  are  all  the  signs  of 
a  localized  empyema.  Such  cases  show  localized  dulness  or  flatness, 
bronchophony,  and  absence  of  fremitus  in  a  certain  portion  of  the 
chest,  generally  at  the  lower  portion  behind.  A  needle,  on  being 
introduced,  withdraws  pus,  which  in  the  cases  I  have  seen  was  min- 
gled with  air  bubbles.  On  operation,  the  pleura  is  found  to  be  normal. 
In  three  instances  I  found  this  to  be  true.  The  evidence  of  a  bron- 
chiectatic cavity  lay  in  the  persistence  of  signs  and  symptoms  after 
the  healing  of  the  chest  wounds.  In  all  3  cases  the  expectoration 
persisted  in  profuse  quantities  after  operation  (Fig.  123). 

Physical  Signs. — The  physical  signs  in  all  of  my  cases  included  a 
localized  area  of  dulness  or  flatness,  over  which  there  was  broncho- 
phony and  bronchial  breathing,  in  some  cases  with  gurgles.  Above 
this  area,  over  the  base  behind,  there  was  on  percussion  a  tympanitic 
note,  indicating  the  enlarged  bronchus  containing  air.  Tuberculosis 
is  excluded  by  the  absence  of  tubercle  bacilli  in  the  sputum,  though 
bronchiectasis  and  tuberculosis  may  coexist.  In  most  of  my  cases 
there  was  a  history  of  an  antecedent  attack  of  pneumonia.  Exclusion 
of  abscess  of  the  lung  is  very  difficult  in  severe  cases  in  which  the 
quantity  of  sputum  is  excessive.  The  bronchiectatic  cavity  in  these 
cases  is  very  large.  With  the  bronchiectasis,  there  may  be  diffuse 
bronchitis  and  emphysema  of  the  lung. 

Course, — Soiue  of  the  cases  in  which  the  bronchiectasis  is  not 
marked  or  progressive  result  in  spontaneous   recovery.     In  others 

39 


610 


DISEASES    OF    THE    EESPIEATOEY    SYSTEM. 


there  may  be  tuberculosis,  gangrene  of  the  lung,  or  empyema,  as 
complications.  A  fatal  hemoptysis  may  close  the  scene  of  this  very 
offensive  affection. 

Treatment. — Treatment  does  not  give  very  satisfactory  results.  It 
includes  the  inhalation  of  balsams  of  all  kinds,  out-of-door  life  in 
high  altitudes,  and  surgical  interference  including  exposure  of  the 
lung  and  incision  of  the  bronchiectatic  cavity.  The  latter  is  a  des- 
perate remedy ;  in  some  cases  it  has  resulted  in  fatal  hemorrhage  and 
in  others  has  not  afforded  relief.     A  cure  has  resulted  in  a  few  rare 

Fig.  123, 


Showing  bronchiectatic  cavitj'  in  case  of  a  girl  eight  years  of  age,  with  signs  as  noted 

in  text. 

cases  in  which  there  was  a  simple  cavity  in  the  lung  near  the  pleural 
surface.  The  injection  of  these  cavities  with  drugs  has  also  been 
very  unsatisfactory. 


DISEASES  OF  THE  LUNGS. 

General  Considerations. — The  lungs  at  birth  are  small  as  com- 
pared to  the  other  organs  in  the  chest.  They  grow  comparatively 
more  in  the  first  few  months  of  infancy;  but  in  children  they  remain 
small  as  compared  to  the  body-weight  and  length.  Compared  to  the 
heart  in  volume  during  the  first  month  of  infancy,  the  lungs  are  as 
3.5  or  4  to  1.     In  the  later  months  of  infancy  the  lungs  develop  more 


DISEASES    OF    TEE   LUNGS.  611 

rapidly,  and  then  the  ratio  of  volume  of  the  lungs  to  the  heart  is  as 
5.5  or  6.2  to  1. 

Movements  of  the  Chest. — The  movements  of  the  chest  may  nor- 
mally be  irregular  in  rhythm ;  the  sides  move  in  unison. 

In  disease,  especially  in  conditions  of  pressure  on  one  side  of  the 
neck,  one  side  of  the  chest  may  remain  immobile,  the  other  being 
retracted  with  each  respiration  to  an  exaggerated  degree.  I  have 
observed  this  condition  after  operations  for  retropharyngeal  abscess  in 
the  neck,  incases  in  which  the  nerves  in  this  region  were  pressed  upon 
or  injured,  thus  interfering  with  the  normal  action  of  the  diaphragm. 

In  effusion  into  one  side  of  the  chest,  there  is  diminished  motion 
on  the  diseased  side.     Emphysema  may  restrict  the  normal  movements. 

In  forms  of  pleurisy  with  effusion  the  intercostal  spaces  are 
retracted  more  than  is  normal  at  each  descent  of  the  diaphragm. 
This  may  be  due  to  adhesions.  The  precordial  region  may  be  drawn 
inward  with  the  recoil  of  the  heart,  as  is  sometimes  seen  in  adherent 
pericardium. 

Scoliosis  of  the  spine  may  deform  the  chest,  giving  undue  promi- 
nence to  one  side.  Retraction  occurs  after  the  absorption  of  pleuritic 
effusions. 

Fremitus. — The  method  of  obtaining  fremitus  in  children  has 
been  described.  It  may  be  mentioned  here  that  fremitus  is  well 
marked  normally  in  the  posterior  axillary  line  and  in  the  inter- 
scapular region. 

The  Normal  Limits  of  the  Lungs. — In  the  mammillary  line  on 
the  right  side  to  the  sixth  rib ;  in  the  mid-axillary  line  to  the  ninth 
rib.  Posteriorly  on  the  right  side  to  the  tenth  rib ;  on  the  left  side 
to  the  eleventh  rib.  Thus  the  limits  are  practically  the  same  as  in 
the  adult  subject  (Symington). 

The  amount  of  lung-tissue  above  the  clavicle  cannot  be  mapped 
out  in  infants  and  children. 

Resiliency  of  the  Chest-wall. — The  chest-wall  in  infants  and  chil- 
dren has  a  normal  resiliency  to  percussion.     The  wall  yields  beneath 
the  percussing  finger.     This  is  a  definite  feature.     In  any  disease  of 
the  chest  which  interposes  fluid  between  the  chest-wall  and  the  lung 
this  resiliency  of  the  wall  is  diminished  or  absent.     In  infants  and 
children,  as  in  adults,  there  are  normally : 
Pulmonary  resonance ; 
Dulness  varying  to  flatness ; 
Tympanitic  resonance. 

Pulmonary  Resonance. — Pulmonary  resonance  is  lower  in  pitch 
than  in  the  adult.  Anteriorly  over  the  right  infraclavicular  region 
it  is  less  marked  than  on  the  left  side;  the  note  is  also  slightly  higher 
and  of  shorter  duration. 


612 


DISEASES    OF    THE    EESPIEATOEY    SYSTEM. 


Dulness. — Dulness  is  found  normally  over  the  heart,  liver,  and 
spleen ;  ako,  anteriorly  on  the  right  side  from  the  fourth  to  the  sixth 
rib.  From  the  sixth  rib  to  the  borders  of  the  ribs  the  note  is  flat. 
In  the  mid-axillary  line  on  the  right  side  there  is  dulness  from  the 
fifth  to  the  seventh  rib;  from  this  point  to  the  free  border,  the  note 
is  quite  flat.  On  the  left  side  at  the  level  of  the  sixth  rib,  just  above 
the  spleen,  there  is  a  narrow  strip  of  relative  dulness,  due  to  the  pres- 
ence beneath  the  diaphragm  of  the  left  lobe  of  the  liver  (Fleischman) 
(Fig.  124). 

Fig.  124. 


SI  rip  of  relative  dulness  described  by  Fleischiiiaii.  :in<l   inninl  Just  nbove  the  spleen,  snp- 
jxjsed  to  be  due  to  the  presence  of  tlie  loft  lobe  of  ilu-  liver.      Child,  two  years  of  age. 


Posteriorly  the  supras])iii()us  regions  give  dulness,  but  not  so 
markedly  as  in  the  adult.  On  the  right  side,  from  the  level  of  the 
seventh  dorsal  vertebra,  exit  ii<liiig  dowiiwai-d,  ihere  is  dulness  due 
to  the  liver. 


DISEASES    OF    THE    LUNGS.  613 

Tympanitic  Resonance. — Tympanitic  resonance  due  to  the  stomach 
is  found  normally  in  the  left  axillary  line.  It  may  in  some  cases 
extend  high  up  in  the  axilla. 

Auscultation. — As  a  rule,  there  is  little  difficulty  in  obtaining  the 
respiratory  murmur  and  voice-sounds  in  infants  and  children — cer- 
tainly not  in  the  latter.  The  crying  of  unruly  infants  is  useful  in 
that  it  gives  the  fremitus  and  the  quality  of  the  voice-sounds.  In 
some  cases  the  infants  are  very  quiet  during  examination,  and  unless 
they  are  teased  into  crying,  definite  information  on  these  points  can- 
not be  obtained. 

The  Breathing. — The  repiratory  sounds  in  infants  and  children 
are  of  an  intensified  vesicular  quality;  this  so-called  puerile  breath- 
ing is  normal  and  constant  in  children  under  twleve  years  of  age. 
The  quality  of  the  vesicular  murmur  is  probably  caused  by  the  better 
conducting  qualities  of  the  chest  at  this  age.  The  elasticity  of  the 
lungs,  which  causes  greater  resistance  to  the  inspiratory  dilatation, 
is  also  a  factor  in  producing  the  puerile  quality  of  the  respiratory 
sounds  (Gutman). 

Types  of  Puerile  Breathing. — Puerile  breathing  in  infants  and 
children  may  be  classified  as  follows : 

a.  The  most  common  type  is  that  in  which  the  inspiration  is 
coarse  or  intense  in  quality,  while  the  expiration  is  vesicular  and 
almost  inaudible. 

h.  The  second  type  of  puerile  breathing  is  that  in  which  the  inspi- 
ration and  expiration  are  both  of  an  intensified  coarse  quality. 

c.  The  third  type  is  that  in  which  the  inspiratory  sound  is  low 
and  vesicular,  and  the  expiratory  coarse  and  puerile. 

These  types  are  found  in  infants  and  children  at  rest.  If  they 
are  caused  to  cry,  both  the  inspiratory  and  expiratory  murmur  are 
of  a  coarse  puerile  quality.  In  some  infants  and  children  at  rest, 
the  inspiration  and  expiration  are  vesicular  as  in  the  adult.  Puerile 
breathing  is  frequently  confounded  with  bronchial  breathing.  It  is, 
however,  never  tubular  in  quality.  Bronchial  or  tubular  breathing  is 
marked  on  expiration ;  puerile  breathing  is  marked  on  inspiration. 

During  auscultation  the  sides  of  the  chest  are  always  compared. 
On  the  right  side,  beneath  the  clavicle  and  over  the  spine  of  the 
scapula,  the  expiratory  murmur  is  more  intense  than  on  the  left  side. 
This  should  be  especially  remembered  in  cases  in  which  disease  of 
the  right  apex  is  suspected.  The  quality  of  the  breathing  in  these 
regions  approaches  the  bronchovesicular. 

Posteriorly,  the  respiratory  murmur  may  be  heard  as  far  down  as 
the  level  of  the  eleventh  dorsal  vertebra.  In  some  children  the 
sounds  are  not  so  intense  toward  the  base  of  the  lung  behind  as 
higher  up  in  the  chest. 


614  DISEASES    OF    THE    BESPIBATOBY    SYSTEM. 

Bronchovesicular  Breathing. — Bronchovesicular  breathing  is  heard 
normally  in  the  interscapular  region  in  children  as  in  adults.  It  has 
the  same  qualities  as  in  the  adult. 

Bronchial  Breathing. — Bronchial  breathing  is  heard  normally  over 
the  trachea  and  upper  part  of  the  sternum.  It  is  also  called  tubular, 
tracheal,  and  over  the  larynx,  laryngeal  breathing. 

Forms  of  Dyspnoea. — Though  mainly  of  two  types,  pulmonary 
and  laryngeal,  dyspnoea  may  be  caused  by  pain,  fever,  cardiac  dis- 
ease, and  abdominal  tumors. 

Pulmonary. — There  is  not  only  an  increase  in  the  number  of 
respiratory  movements,  but  also  a  change  in  the  depth  of  each  respira- 
tory effort.  In  the  dyspnoea  of  pulmonary  disease,  the  region  at  the 
border  of  the  ribs  adjacent  to  the  abdominal  walls  (peripneumonic 
groove)  is  drawn  forcibly  inward  at  each  inspiration.  In  emphy- 
sema with  asthmatic  attacks,  it  will  be  noticed  that  during  the  attack 
the  upper  part  of  the  thorax  is  immobile,  the  inferior  part  being 
drawn  inward  with  each  inspiratory  effort.  The  presence  of  fluid 
in  one  side  of  the  chest  may  be  suspected  if  the  side  remains  immo- 
bile, or  if  the  intercostal  spaces  are  drawn  inward  with  each  forced 
inspiration.  A  splenic  or  nephritic  tumor  may  also,  by  simple  up- 
ward pressure,  immobilize  one  side  of  the  chest. 

Laryngeal. — Laryngeal  dyspnoea  will  occur  in  any  obstructive  dis- 
ease of  the  larynx.  In  addition  to  the  phenomena  of  the  pulmonary 
form  of  dyspnoea,  there  is  a  distinct  retraction  of  the  tissues  at  the 
situation  of  the  suprasternal  notch.  There  may  also  be  laryngeal  or 
croupy  breathing. 

While  this  is  true  in  the  majority  of  cases,  I  have  also  seen  the 
retraction  of  the  suprasternal  notch,  described  above,  present  in  the 
later  stages  of  severe  forms  of  acute  pulmonary  disease,  especially  in 
children;  also  in  cases  of  emphysema  in  the  asthmatic  attack. 

Pain. — Pain  will  cause  an  increase  in  the  number  of  respiratory 
movements.  Thus  the  pain  of  an  incipient  pleurisy  will  cause  an 
increased  number  of  respirations  which  are  more  shallow  than  is 
normal.  Peritonitic  pain  will  also  cause  the  respirations  to  become 
shallower  and  to  increase  in  number. 

Fever. — Pever  will,  especially  in  infants  and  children,  increase 
the  number  of  respiratory  movements  to  40  or  more,  without  the 
presence  of  any  lung  disease. 

Cardiac. — Cardiac  dyspnoea  is  seen  in  those  diseases  of  the  heart 
which  cause  a  retardation  of  the  pulmonic  circulation.  The  aeration 
of  the  blood  in  the  capillaries  of  the  lung  is  considerably  interfered 
with  under  these  conditions.  Mitral  disease,  stenosis,  and  regurgi- 
tation cause  dyspnoea  not  only  for  the  reason  given  above,  but  also,  in 
the  later  stages,  on  accoimt  of  the  bronchitis  which  is  the  result  of 


DISEASES    OF    THE    LUNGS.  615 

the  cardiac  disease.  Anaemia  of  cardiac  disease  is  also  accompanied 
by  a  slight  dyspnoea,  which  is  especially  marked  in  children.  The 
slightest  exertion  will  sometimes  cause  angina  and  dyspnoea  in  chil- 
dren suffering  from  a  slight  cardiac  lesion. 

Ascites  and  Abdominal  Tumors. — Ascites  or  abdominal  tumors,  or 
enlarged  organs,  such  as  the  liver  or  spleen,  will  cause  dyspnoea, 
especially  when  patients  are  in  the  recumbent  position. 

In  weak  infants  a  few  days  old,  who  are  the  subjects  of  atelectasis 
and  pneumonia,  the  upper  part  of  the  chest-wall  moves  very  little, 
while  the  inferior  portion  of  the  chest  and  the  upper  part  of  the  abdo- 
men (peripneumonic  groove)  are  drawn  inward  at  each  inspiration. 

Lobar  Pneiimonia  (Fibrinous  Pneumonia^  Croupous  Pneumonia 
or  Pneumonic  Fever). — Lobar  pneumonia  or  fibrinous  pneumonia 
is  an  acute  infectious  disease,  caused  in  the  majority  of  cases  by  the 
Diplococcus  pneumoniae  (Frankel).  A  few  cases  are  caused  by  the 
Bacillus  pneumoniae  (Friedlander)  ;  others,  by  the  Streptococcus  or 
Staphylococcus  pyogenes. 

Occurrence. — Lobar  pneumonia  occurs  as  a  primary  disease  or 
may  complicate  typhus  fever,  typhoid  fever,  influenza,  rheumatism, 
malarial  fever,  erysipelas,  osteomyelitis,  meningitis,  and  nephritis. 
According  to  Keller,  from  58  to  62  per  cent,  of  all  lobar  pneumonias 
occur  among  children,  the  frequency  among  boys  being  greater  (55.9 
per  cent.).  Fully  two-thirds  of  the  cases  occur  during  the  winter 
and  early  spring.  Pneumonia  of  any  variety,  and  especially  of  this 
form,  may  occur  in  groups  of  persons  or  in  small  local  epidemics. 
Without  doubt  certain  houses  and  rooms  harbor  the  pneumonia  poi- 
son for  some  time,  as  is  evinced  by  the  repeated  occurrence  of  cases 
in  certain  places  (Jlirgensen).  Cold  favors  the  development  of 
pneumonia  by  reducing  the  resistance  of  the  economy  to  the  invasion 
of  bacteria,  but  it  cannot  be  regarded  as  a  cause  of  the  disease. 

Age. — Lobar  pneumonia  may  occur  at  any  age  of  infancy  or  child- 
hood. Von  Jaksch  has  shown  that  it  occurs  among  young  infants. 
My  own  experience  confirms  this  statement.  Out  of  839  of  my  cases 
of  pneumonia  of  all  types,  582,  or  69  per  cent.,  occurred  before  the 
end  of  the  second  year ;  the  greatest  frequency  was  between  the  first 
and  second  years  (282  cases).  From  birth  to  the  sixth  month  the 
frequency  is  less  than  from  the  sixth  month  to  the  end  of  the  second 
year. 

Sex.- — The  male  sex  shows  the  greater  number  of  cases  (436 
males,  403  females). 

Seat  of  the  Disease. — Jlirgensen  shows  that  in  162  cases,  both 
lungs  were  affected  in  7.4  per  cent.  The  right  lung  only  was  affected 
in  43.2  per  cent,  of  the  cases.  When  the  right  lung  was  attacked,  the 
lower  lobe  was  generally  the  seat  of  the  disease   (25.3  per  cent.). 


616  DISEASES    OF    THE    BESPIEATORY    SYSTEM. 

The  lower  lobe  of  the  left  lung  was  consolidated  in  35  per  cent,  of 
the  cases. 

Of  217  of  my  cases  of  lobar  pneumonia,  the  right  limg  was 
involved  in  124  cases  and  the  left  in  93;  the  upper  right  lobe  was 
involved  in  74  cases;  the  upper  left  in  35.  The  upper  lobe  of  either 
lung  was  involved  in  109  cases,  as  against  100  cases  of  the  lower 
lobes.     The  middle  right  lobe  was  involved  in  only  8  cases. 

Upper  lobe.        Middle  lobe.        Lower  lobe. 

Eight  lung 74  8  42 

Left  lung 35  —  58 

Pneumonia  of  the  upper  lobe  is  more  frequent  in  children  than 
in  adults.  According  to  Jlirgensen,  the  greater  frequency  of  pneu- 
monia in  the  right  lung  may  be  attributed  to  the  larger  size  of  the 
right  bronchus  and  the  more  direct  communication  with  the  lung. 

Morbid  Anatomy.  ^ — Lobar  pneumonia  in  infancy  and  childhood  is, 
as  in  adult  life,  distinguished  by  the  occurrence  of  a  fibrinous  exudate 
in  the  alveoli  of  the  lungs,  bronchioles,  and  lymph-spaces.  This 
exudate  is  composed  of  desquamated  epithelium,  leucocytes,  red-blood 
cells,  and  fibrin.  The  proportion  of  leucocytes,  red  blood-cells,  and 
fibrin  varies  greatly  at  different  stages  of  the  affection.  A  fluid 
exudate  may  be  present  if  the  quantity  of  fibrin  is  small.  In  such 
cases  there  is  a  lobar  catarrhal  process  or  an  inflammatory  oedema  of 
the  lung.  The  exudate  begins  with  congestive  hypersemia.  The 
lung  is  dark  red  and  of  increased  consistency.  With  the  appearance 
of  coagulation  there  is  produced  a  condition  of  hepatization  in  which 
the  lung  is  solid,  and  has  the  appearance  of  liver.  The  bloodvessels 
are  filled  with  red  cells.  If  the  vessels  are  less  engorged,  the  lung- 
has  a  grayish  tint. 

This  later  stage,  called  gray  hepatization,  is  the  condition  most 
frequently  seen  at  autopsy.  The  hepatized  lung  does  not  contain 
any  air,  and  on  section  shows  a  granular  surface,  the  granules  being 
the  so-called  pneumonic  granules  of  the  later  stage  of  the  disease. 
The  pleura  is  as  a  rule  inflamed.  It  is  without  lustre  and  may  be 
thickened  and  covered  with  fibrin.  There  may  be  considerable  serous 
or  seropurulent  exudate  in  the  pleural  cavity.  The  extent  of  hepati- 
zation varies.  It  may  involve  a  whole  lobe,  part  of  the  lobe  of  a  lung, 
or  parts  of  both  kings.  On  inspection  of  the  surface  of  a  section, 
small  yellow  areas  luay  be  seen  in  the  hepatized  portions.  These 
are  areas  poor  in  fibrin,  and  correspond  to  the  situation  of  the  bron- 
chioles of  the  lung. 

The  bronchial  nodes  may  be  red  and  swollen,  the  bronchi  being 
the  seat  of  inflammation.  The  bronchioles  may  l)e  filled  with  fibrin 
and  red  blood-cells. 


DISEASES    OF    THE    LUNGS.  6 1  i 

Resolution  occurs  on  from  the  seventh  to  the  tenth  day  of  the 
disease.  At  this  time  liquefaction  of  the  inflammatory  products 
which  are  eliminated  by  expectoration  occurs.  Complete  restoration 
of  the  lung  to  the  normal  may  occur  between  the  second  and  the 
fourth  week,  at  which  time  the  periphery  of  the  alveoli  may  be  found 
to  be  rich  in  cells.  There  may  still  exist  catarrhal  processes  which 
have  succeeded  the  fibrinous  changes.  The  pleura  may  remain  thick- 
ened and  be  the  seat  of  adhesions. 

An  unfavorable  or  malignant  ending,  such  as  gangrene  or  suppu- 
ration, is  rare,  and  is  as  a  rule  due  to  some  mixed  infection  favored 
by  an  old  bronchiectasis  or  putrid  bronchitis.  Unless  a  tuberculous 
infection  occurs,  caseation  in  lobar  pneumonia  is  unknown.  Indu- 
ration of  the  lung,  cirrhosis  or  carnification,  is  a  peculiar  condition 
which  may  occur  from  the  fourth  to  the  tenth  week.  The  lung- 
assumes  a  beefy  red  appearance  and  is  tough,  hypersemic,  and  infil- 
trated with  small  round  cells.  The  alveoli  enclose  a  large  number 
of  connective-tissue  cells.  There  is  a  proliferation  of  newly  formed 
bloodvessels  in  the  septa  of  the  lung.  The  bronchial,  peribronchial, 
and  pleural  tissues  are  proliferated.  Induration  of  the  lung  by 
pleural  adhesions  results.  The  alveoli  of  the  lung  may  be  replaced 
by  connective  tissue  and  epithelium.  Induration  may  take  the  form 
of  bands  of  connective  tissue,  which  may  extend  from  the  pleura  into 
the  lung,  enclosing  areas  of  lung-tissue. 

Bacteriology  and  Etiology. ^ — The  pneumococcus  of  Frankel  is  now 
recognized  as  the  etiological  factor  in  lobar  pneumonia.  The  Ba- 
cillus pneumonise  of  Friedlander  is  found  in  a  small  number  of 
cases,  with  the  pneumococcus  or  with  other  bacteria.  The  Strep- 
tococcus pyogenes  and  the  Staphylococcus  pyogenes  are  sometimes 
found,  as  well  as  the  Bacillus  typhosus.  In  the  cases  of  secon- 
dary infection,  the  Diplococcus  pneumoniae  or  the  Staphylococcus 
pyogenes  is  found.  In  the  majority  of  fatal  oases,  Kohn  found  the 
pneumococcus  circulating  in  the  blood.  The  cases  which  show  the 
diplococcus  in  the  blood  and  which  recover,  do  so  with  complications. 
In  a  recurrent  pneumonia  of  infancy,  Perutz  found  an  osteomyelitis 
of  the  joint,  caused  by  pneumococci.  In  one  of  my  cases  which  was 
followed  by  bilateral  empyema,  there  was  a  peri-articular  abscess  con- 
taining pneumococci.  According  to  Landouzy  and  IsFetter,  the  pneu- 
mococcus is  capable  of  producing  suppuration  without  the  interven- 
tion of  streptococci  or  staphylococci.  Cases  of  severe  icterus  are  due 
to  the  hsemolytic  action  of  the  pneumococci  on  the  blood.  Gaillard 
has  shown  that  the  enteritis  in  pneumonia  is  caused  by  pneumococci. 
Symptomatology. — There  are  forms  of  fibrinous  or  lobar  pneu- 
monia which  present  the  same  symptomatology  in  children  as  in  the 
adult.     On  the  other  hand,  certain  sets  of  symptoms  referable  to  the 


618  DISEASES    OF    THE    BESPIBATOEY    SYSTEM. 

nervous  system  and  intestinal  tract,  as  well  as  the  character  of  the 
variations  in  temperature,  are  peculiar  to  infancy  and  childhood. 

The  disease  may  be  ushered  in  by  a  chill,  which  may  be  severe 
or  only  amount  to  a  sensation  of  chilliness.  Susceptible  subjects 
may,  with  the  rise  of  temperature,  be  attacked  with  convulsions. 
Other  patients  pass  into  a  stage  of  delirium  lasting  for  days.  Cases 
of  pneumonia  ushered  in  with  cerebral  symptoms  are  apt  to  mislead 
the  physician,  especially  if  meningitis  has  been  recently  prevalent. 
There  are  also  cases,  especially  in  children,  in  which  there  has  been 
a  preceding  bronchitis.  These  should  not  be  regarded  as  being  of 
necessity  cases  of  bronchopneumonia.  Sometimes  the  chill  is  coin- 
cident with  a  sharp  attack  of  enteritis.  The  character  of  the  invasion 
will  thus  vary  with  the  severity  of  the  infection  and  the  susceptibility 
of  the  subject. 

After  the  initial  chill,  there  is  in  the  simple  cases  a  sharp  rise  of 
temperature.  The  height  of  the  fever  varies,  and  in  young  infants 
is  apt  to  mount  to  106°  F.  (41.1°  C).  There  are  cough  and  consid- 
erable dyspnoea,  varying  with  the  extent  of  lung  involvement. 

In  infants  and  children  the  dyspnoea  is  quite  apparent  to  the  eye 
of  the  observer,  and  will  prompt  him  to  surmise  that  the  lung  is 
involved.  Older  children  have  a  distressed  expression.  In  cases  in 
which  sopor  is  present,  the  dyspnoea  is  apt  to  be  more  evident  than 
in  those  cases  in  which  this  cerebral  symptom  is  absent.  This  appar- 
ent dyspnoea  is  only  relative.  A  conscious  patient  does  not  show  this 
dyspnoea  as  much  as  one  who  is  unconscious. 

The  patient  complains  of  pain,  which  is  in  many  cases  referred 
to  the  side  affected.  In  younger  children  the  pain  is  quite  frequently 
referred  to  the  epigastrium,  but  sometimes  to  the  region  of  the  abdo- 
men low  down,  or  to  the  right  side  of  the  abdomen  low  down  over  the 
situation  of  the  vermiform  appendix.  Pain  is  apt  to  be  referred  to 
this  region  in  cases  of  lobar  consolidation  of  the  lower  portion  of  the 
right  lung.  These  are  often,  in  the  early  stages,  diagnosed  as  cases 
of  appendicitis.  The  face  is  pale  or  quite  flushed.  The  dyspnoea 
may  be  slight,  but  is  quite  marked  in  some  severe  cases.  Even  if 
both  lungs  are  involved,  it  may  not  be  intense. 

There  is  a  cough.  In  older  children  there  is  expectoration  of 
rusty  sputum.  Infants  and  young  children  swallow  the  sputum. 
Infants  cry  with  each  paroxysm  of  coughing ;  older  children  complain 
of  pain.  Sometimes  infants  and  children  vomit  with  each  attack 
of  coughing.  After  the  fever  has  persisted  with  these  symptoms  for 
from  five  to  nine  days,  there  occurs  in  the  vast  majority  of  cases  a 
fall  of  the  temperature — the  so-called  crisis — which  may  take  place 
within  from  three  to  six  hours,  or  may  extend  over  thirty-six  hours. 
The  fall  of  temperature  may  be  followed  by  a  temporary  rise  of  a  few 


DISEASES    OF    THE    LUNGS. 


619 


degrees  (Fig.  125)- — the  so-called  pseudocrisis ;  within  a  few  hours 
it  then  falls  to  the  subnormal,  where  it  remains  for  a  few  days  after 
the  crisis,  finally  rising  to  the  normal  and  remaining  at  that  point 
throughout  convalescence.  The  temperature  may  fall  by  lysis,  that 
is  to  say,  by  reaching  with  gradual  remissions  the  normal,  or  as  a 
rule  the  subnormal,  within  from  forty-eight  to  seventy-two  hours. 


Fig 

125. 

SoNTH 

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Lobar  pneumonia ;  pseudocrisis  and  crisis.     Leucocyte  count  before  and  after  crisis  indi- 
cated.    Boy,  four  years  of  age. 


Individual  Symptoms. — Temperature. — The  temperature-curve  in 
lobar  or  fibrinous  pneumonia  may  be  of  several  distinct  types.  In 
the  majority  of  cases  the  temperature  remains  persistently  high  for 
the  whole  period  of  the  illness.  There  are  morning  remissions  of  a 
degree  or  more,  but  the  afternoon  or  evening  rise  may  reach  104°, 
105°,  106°  F.  (40°,  40.5°,  41.1°  C).  In  a  typical  case  the  morn- 
ing remissions  are  not  so  great  as  those  in  pneumonia  of  the  broncho- 
pneumonic  type.  The  crisis  is  not  as  a  rule  preceded  by  a  rise.  The 
drop  of  the  temperature  at  the  crisis  in  a  fairly  typical  case  may 
begin  at  9  a.  m.,  and  the  temperature  may  be  subnormal  at  9  p.  m. 
of  the  same  day  (Fig.  126).  In  another  form,  crisis  may  be  rapidly 
followed  by  a  temporary  rise  in  the  temperature,  not  due  to  any  rein- 


620 


DISEASES    OF    THE    FiESPIBATOB¥    SYSTEM. 


fection  of  the  lung,  but  to  a  slight  post-pneimionic  toxsemia.  The 
temperature  will  in  such  cases  reach  the  subnormal  within  thirty- 
six  hours. 

Fio.  126. 


HOUR 

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Lobar  pneumonia,  right  lung,  lower  lobe.     Crisis  on  the  eighth   day.     Leucocyte  count 
indicated.     Female  child,  two  years  and  Ave  months  of  age. 

Fig.  127. 


HOUR      3  is    9  12  3    6    9  12  3 

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UR.NE                     XXX         XX 

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Lobar  pneumonia,  right  lung,  lower  lolie:  lemperature  falls  by  lysis.      Leucocytosis  indi- 
cated in  the  chart.     Female  child,  four  years  of  age. 


Another  very  di.stinct  form  of  temperature-curve  is  the  remittent. 
This  temperature-curve  is  at  first  glance  exactly  similar  to  that  of 
bronchopneumonia.  The  remissions  in  the  morning  may  reach  the 
normal  within  a  fraction  of  a  degree.     Such  cases  may  also  show  at 


DISEASES    OF    THE    LUNGS. 


621 


the  terminal  end  of  the  curve  a  critical  drop  to  the  normal.  In 
other  cases  the  fall  of  temperature  at  the  beginning  of  convalescence 
takes  place  by  v^hat  is  known  as  lysis  (Fig.  127).  In  other  words, 
the  temperature  reaches  the  normal  or  subnormal  by  remission  of 
temperature  in  a  gradually  descending  scale  extending  over  two  or 
more  days.  Some  cases  show  a  remission  of  the  temperature  which 
begins  at  the  ninth  day  of  the  disease,  and  is  not  completed  until  the 
fifteenth  day.  This  is  occasionally  seen  in  cases  in  which  there  are 
apparently  no  complications.  The  more  common  type  is  that  in 
which  the  lysis  begins  on  the  seventh  or  eighth  day,  and  is  completed 
in  two  or  three  days.  Of  57  cases  of  lobar  pneumonia  in  which  a 
reliable  history  could  be  obtained,  the  temperature  fell  by  crisis  in  36 
and  by  lysis  in  21  cases.      The  crisis,  as  a  rule,  occurs  from  the  fifth 


Fig 

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LEUCO- 
CYTES 

14,000 
10,600 
15,000 
10,600 

10,000 

18,200 
11.400 

Lobar  pneumonia,  right  lung,  middle  lobe  ;  effusion  into  the  pleura.     Temperature  after 
crisis  due  to  pleurisy.     Boy.  eight  years  of  age. 

to  the  ninth  day  of  the  disease  (60  per  cent,  of  my  cases).  After 
the  lysis  or  crisis  there  may  be  a  slight  daily  rise  in  temperature  of 
a  degree  or  even  less,  probably  indicative  of  a  very  mild  form  of  post- 
pneumonic pleurisy.  The  temperature  in  such  cases  falls  gradually, 
and  in  four  or  five  days  reaches  the  normal  (Fig.  128). 

The  subnormal  temperature  after  the  crisis  or  lysis  is  quite  a 
common  phenomenon.  I  have  learned  not  to  fear  this  symptom,  but 
to  regard  it  as  favorable  (Fig.  129).  A  subnormal  temperature  may 
persist  for  days,  or  even  a  week  or  longer,  and  not  uncommonly,  espe- 
cially in  fibrinous  pneumonia  which  has  run  a  sharp  or  moderately 
severe  course,  is  accompanied  by  irregularity  or  abnormal  slowness 
of  pulse.  A  slow  pulse  (bradycardia)  which  is  at  the  same  time 
regular  is  apt  to  alarm  the  physician^  but  I  have  never  seen  any  ill 
effects  in  these  cases  if  they  were  treated  in  a  rational  manner.  Such 
conditions  of  pulse  and  temperature  should  be  regarded  as  a  result 
of  the  toxsemia  which  has  affected  the  heart  muscle. 


622 


DISEASES    OF    THE    EESPIEATOEY    SYSTEM. 


Chills. — Chills,  or  chilly  sensations  followed  by  a  rise  of  tempera- 
ture during  the  course  of  the  disease,  are  in  most  cases  accompanied 
by  physical  signs  of  an  invasion  of  a  new  area  of  lung.  This  should 
at  least  be  kept  in  mind,  especially  if  the  rise  of  temperature  is  abrupt. 

At  the  crisis  in  lobar  pneumonia  I  have,  in  exceptional  cases,  seen 
the  temperature  drop  within  an  hour  from  103°  to  94°  F.  (34.4°  to 
39.9°  C.)  and  the  pulse  to  48;  within  an  hour  the  temperature  rose 
to  96°  F.  (35.5°  C.)  and  the  pulse  to  TO.  The  temperature  grad- 
ually rose,  so  that  within  seven  hours  it  was  again  99°  F.  (37,2°  C.) 
in  the  rectum,  the  pulse  96.  The  symptoms  of  mild  collapse  may 
accompany  the  pronounced  fall. 

Cough. — Some  infants  and  children  cough  very  little;  in  others 
the  cough  is  a  very  harassing  symptom.  There  is  no  sputum  even  in 
the  older  children,  or  only  after  the  crisis;  pain  accompanies  the 

Fig.  129. 


Lobar  pneumonia,  light  lung,  upper  lobe  :  remittent  temperature-curve  ;  prolonged 
subnormal  temperature  intermittent  in  character ;  recovery.  Female  child,  two  vears 
and  six  months  of  age. 


cough,  and  may  be  suspected  if  the  infant  or  child  cries  when  it 
coughs.  The  pain  is  referred  to  the  side  of  the  chest,  to  the  epigas- 
trium, or  to  the  region  of  the  umbilicus  or  appendix.  The  pain 
referred  to  the  appendix  in  cases  of  lobar  pneumonia  is  probably 
radiated  from  a  diaphragmatic  pleurisy. 

Dyspnoea. — Infants  and  young  children  show  marked  dyspnoea. 
The  alse  nasi  are  dilated  and  the  peripneumonic  groove  is  depressed 
with  each  inspiration.  In  very  severe  dyspnoea  in  young  infants, 
there  may  be  a  drawing  inward  at  the  suprasternal  notch.  This 
occurs  even  in  the  absence  of  any  laryngeal  disturbance,  and  fre- 
quently simulates  laryngeal  stenosis. 

Nervous  Symptoms. — The  cerebral  symptoms  may  at  the  outset 
simulate   those   of   menina-ifis    fmeningisnO-      There   are    delirium. 


DISEASES    OF    THE    LUNGS.  623 

rigidity  of  the  muscles  of  the  neck,  and  even  opisthotonos.  There 
may  be  no  true  meningitis.  Older  children  may  have  a  low,  mutter- 
ing delirium  during  the  whole  course  of  the  disease.  Xear  the  crisis 
and  just  before  the  fall  of  temperature,  I  have  in  a  few  cases  seen 
maniacal  delirium,  in  which  the  patients  were  very  noisy  and  at- 
tempted to  get  ou-t  of  bed.  I  have  seen  cases  of  melancholia  with 
crying  spells  during  convalescence  in  female  children,  and  also  in 
boys.  These  symptoms  all  subsided  in  time  and  the  patients  were 
eventually  fully  restored. 

Blood. — It  has  been  noted  by  Tumas  and  von  Jaksch  that  in  pneu- 
monia of  the  fibrinous  variety  there  are  a  marked  leucocytosis  and  an 
increase  in  the  multinuclear  leucocytes,  which  is  especially  marked  at 
or  near  the  crisis.  The  proportion  of  leucocytes  to  the  red  blood-cells  in 
the  cubic  millimetre  may  reach  1 :  40  to  1 :  70.  Ehrlich  believes  this 
leucocytosis  to  be  a  very  constant  occurrence  in  typical  pneumonia. 
Billings  has  investigated  the  relationship  of  the  leucocytosis  to  the 
prognosis  more  fully.  His  work  will  be  referred  to  in  the  considera- 
tion of  the  prognosis.  My  own  experience  covers  a  large  number  of 
cases  of  fibrinous  and  bronchopneumonia,  examined  with  reference  to 
leucocytosis.  Leucocytosis  is  present  in  both  forms  of  pneumonia  in 
infancy  and  childhood,  but  is  more  marked  in  the  fibrinous  forms,  the 
number  of  leucocytes  to  the  cubic  millimetre  being  about  twice  as 
great  as  in  the  catarrhal  forms.  There  is  marked,  leucocytosis  in 
the  fatal  cases  of  both  forms  of  pneumonia. 

The  increase  of  the  leucocytes  in  the  fibrinous  forms  was  espe- 
cially marked  at  the  time  of  the  crisis.  In  the  bronchopneumonic 
forms  the  leucocytes  were  also  high  at  or  about  the  time  of  the  drop 
in  temperature.  The  diminution  of  the  number  of  leucocytes  was  in 
both  forms  marked  either  just  previous  to  or  after  the  fall  in  the 
temperature.  From  the  observations  of  Billings  and  Ewing,  it  must 
be  concluded  that  leucocytosis  is  a  favorable  sign  in  fibrinous  pneu- 
monia. It  does  not,  however,  as  Ewing  believed,  bear  any  exact  ratio 
to  the  extent  of  lung  involved.  I  have  found  a  much  higher  per- 
centage of  leucocytes  to  the  cubic  millimetre  in  children  than  Ewing 
found  in  the  adult.  This  is  probably  due  to  the  fact  that  any  leuco- 
cytosis is  more  marked  in  infants  and  children  than  in  the  adult  sub- 
ject. The  absence  of  leucocytosis  is  certainly  a  grave  prognostic  sign, 
but  the  presence  of  marked  leucocytosis  in  children  does  not  in  my 
experience  preclude  a  fatal  issue. 

Physical  Signs. — The  signs  obtained  by  physical  examination  of 
the  chest  in  fibrinous  pneumonia  of  infants  and  children  resemble 
those  of  the  same  condition  in  the  adult.  In  forms  of  bronchopneu- 
monia or  catarrhal  pneumonia  in  which  areas  of  considerable  extent 
are  consolidated  the  signs  will  closely  resemble  those  obtained  in  the 


626 


DISEASES    OF    THE    BESPIBATOBY    SYSTEM. 


cases  of  Levy  and  Jlirgensen  were  fatal  within  twenty-four  to  thirty- 
six  hours.  I  have  never  observed  such  cases  of  fibrinous  pneumonia 
in  children,  but  have  seen  lobar  pneumonia  with  a  history  of  short 
duration  (Fig.  130).  In  cases  running  a  very  short  course  there  is 
doubt  as  to  whether  the  signs  obtained  over  the  chest  may  not  have 
been  connected  with  a  preceding  attack.  Henoch  has,  however,  met 
a  few  cases  which  ran  a  rapidly  fatal  course,  with  the  whole  symp- 
tomatology of  lobar  pneumonia,  including  physical  signs,  in  forty- 
eight  hours. 

Fig.  130. 


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103^ 

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Lobar  pneumonia,  midregion  of  the  right  lung  ;  crisis  on  the  fourth  day  of  disease, 
seven  years  of  age.      (Author's  case.) 


Boy, 


Complications. — Among  the  complications  of  fibrinous  pneumonia 
in  infants  and  children  are  otitis,  pleurisy,  pericarditis,  endocarditis, 
empyema,  and  meningitis,  arthritis  and  osteomyelitis  and  peritonitis. 
Gastro-enteritis  is  quite  a  common  complication. 

Otitis. — Otitis  is  common,  its  frequency  varies  in  diiferent  epi- 
demics. It  affects  younger  children  and  infants  more  frequently 
than  older  subjects.  The  temperature  in  these  cases  becomes  more 
markedly  remittent  and  remains  higher  for  a  greater  length  of  time 
than  in  the  uncomplicated  cases.  I  have  frequently  suspected  otitis 
from  a  study  of  the  temjx'vattire-cin'vc,  which  is  not,  however,  an 


DISEASES    OF    THE    LUNGS. 


627 


altogether  reliable  guide.  Suppuration  in  the  pleura  will  give  a 
similar  curve.  Therefore,  in  a  concrete  case  of  persistent  high  tem- 
perature-curve with  morning  remissions,  otitis  should  be  suspected, 
but  not  positively  diagnosed  without  careful  exclusion  of  other  com- 
plications and  otoscopic  examination.  Otitis  as  such  does  not  seem 
to  give  any  strildng  symptoms  of  pain.  The  patient  may  without 
warning  present  perforation  of  the  drum  of  one  or  both  ears  and  a 
purulent  discharge.  The  temperature  will  then  fall  to  the  normal. 
Diplococcus  pneumonige  has  been  found  by  a  number  of  observers  in 
this  discharge.     The  otitis  is  of  a  benign  nature. 

Meningitis. — Meningitis  occurs  in  a  number  of  cases,  and  may 
usher  in  the  disease.     I  have  seen  it  persist  for  weeks.     The  prog- 


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Lobar    pneumonia,    lower    lobe,    left    lung ;    complicating    pleurisy ;    temperature   falling 
gradually  to  the  normal.     Leucocyte  count  indicated.     Boy,  five  years  of  age. 

nosis  in  this  form  of  meningitis,  if  it  assumes  the  cerebrospinal  type, 
is  graver  than  when  it  occurs  as  a  primary  disease,  with  the  intra- 
cellular diplococcus  of  Weichselbaum  as  a  causative  factor.  ISTetter 
seems  to  have  met  a  larger  number  of  cases  of  the  pneumococcus 
form  of  meningitis  than  any  other  author.  The  cases  of  meningitis 
complicating  pneumonia  may  be  due  to  either  the  pneumococcus, 
streptococcus  or  meningococcus.  The  cerebrospinal  symptoms,  or 
meningism,  as  it  is  called,  seen  at  the  outset  or  at  the  crisis  in  some 
cases  of  pneumonia  do  not  last  for  any  great  length  of  time,  and  do 
not  present  the  true  symptoms  of  meningitis.  In  other  cases  it  is 
sometimes  impossible  to  diiferentiate  between  simple  cerebral  symp- 
toms or  the  so-called  meningism  and  the  existence  of  a  complicating 
meningitis.  Even  after  close  study  a  lumbar  puncture  may  be  nec- 
essary to  clear  up  the  diag*nosis. 

Pleurisy  and  Emijyema. — Many  cases  of  fibrinous   pneumonia 


626 


DISEASES    OF    THE    SESPIBATOBT    SYSTEM. 


cases  of  Levy  and  Jiirgenseu  were  fatal  within  twenty-four  to  thirty- 
six  hours.  I  have  never  observed  such  cases  of  fibrinous  pneumonia 
in  children,  but  have  seen  lobar  pneumonia  with  a  history  of  short 
duration  (Fig.  130).  In  cases  running  a  very  short  course  there  is 
doubt  as  to  whether  the  signs  obtained  over  the  chest  may  not  have- 
been  connected  with  a  preceding  attack.  Henoch  has,  however,  met 
a  few  cases  which  ran  a  rapidly  fatal  course,  with  the  whole  symp- 
tomatology of  lobar  pneumonia,  including  physical  signs,  in  forty- 
eight  hours. 

Fig.  130. 


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Lobar  pneumonia,  midregion  of  the  right  lung ;  crisis  on  the  fourth  day  of  disease.     Boy, 
seven  years  of  age.      (Author's  case.) 


Complications. — Among  the  complications  of  fibrinous  pneumonia 
in  infants  and  children  are  otitis,  pleurisy,  pericarditis,  endocarditis, 
empyema,  and  meningitis,  arthritis  and  osteomj'elitis  and  peritonitis. 
Gastro-enteritis  is  quite  a  common  complication. 

Otitis. — Otitis  is  common,  its  frequency  varies  in  different  epi- 
demics. It  affects  younger  children  and  infants  more  frequently 
than  older  subjects.  The  temperature  in  these  cases  becomes  more 
markedly  remittent  and  remains  higher  for  a  greater  length  of  time 
than  in  the  uncomplicated  cases.  I  have  frequently  suspected  otitis 
from  a  study  of  the  temperature-curve,  which  is  not,  however,  an 


DISEASES    OF    THE    LUNGS. 


627 


altogether  reliable  guide.  Suppuration  in  the  pleura  will  give  a 
similar  curve.  Therefore,  in  a  concrete  case  of  persistent  high  tem- 
perature-curve with  morning  remissions,  otitis  should  be  suspected, 
but  not  positively  diagnosed  without  careful  exclusion  of  other  com- 
plications and  otoscopic  examination.  Otitis  as  such  does  not  seem 
to  give  any  striking  symptoms  of  pain.  The  patient  may  without 
warning  present  perforation  of  the  drum  of  one  or  both  ears  and  a 
purulent  discharge.  The  temperature  will  then  fall  to  the  normal, 
Diplococcus  pneumoniae  has  been  found  by  a  number  of  observers  in 
this  discharge.     The  otitis  is  of  a  benign  nature. 

Meningitis. — Meningitis  occurs  in  a  number  of  cases,  and  may 
usher  in  the  disease.     I  have  seen  it  persist  for  weeks.     The  prog- 


Fig 

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Lobar    pneumonia,    lower    lobe,    left    lung ;    complicating    pleurisy ;    temperature   falling 
gradually  to  the,  normal.     Leucocyte  count  indicated.     Boy,  five  years  of  age. 

nosis  in  this  form  of  meningitis,  if  it  assumes  the  cerebrospinal  type, 
is  graver  than  when  it  occurs  as  a  primary  disease,  with  the  intra- 
cellular diplococcus  of  Weichselbaum  as  a  causative  factor.  ISTetter 
seems  to  have  met  a  larger  number  of  cases  of  the  pneumococcus 
form  of  meningitis  than  any  other  author.  The  cases  of  meningitis 
complicating  pneumonia  may  be  due  to  either  the  pneumococcus, 
streptococcus  or  meningococcus.  The  cerebrospinal  symptoms,  or 
meningism,  as  it  is  called,  seen  at  the  outset  or  at  the  crisis  in  some 
cases  of  pneumonia  do  not  last  for  any  great  length  of  time,  and  do 
not  present  the  true  symptoms  of  meningitis.  In  other  cases  it  is 
sometimes  impossible  to  differentiate  between  simple  cerebral  symp- 
toms or  the  so-called  meningism  and  the  existence  of  a  complicating 
meningitis.  Even  after  close  study  a  lumbar  puncture  may  be  nec- 
essary to  clear  up  the  diagnosis. 

Pleurisy  and  Empyema. — Many  cases  of  fibrinous   pneumonia 


628  DISEASES    OF    THE   BESPIEATOBT    SYSTEM. 

show  a  dry  pleurisy  sometimes  persisting  for  a  long  time  after  con- 
valescence. Of  greater  moment  are  the  cases  of  pleurisy  with  effu- 
sion, which  follow  a  lobar  pneumonia.  In  these,  there  is  always  the 
danger  that  the  exudate  may  eventuate  in  an  empyema.  The  dura- 
tion, of  the  exudate  is  no  guide  in  determining  whether  it  is  of  a 
serous  or  a  purulent  nature.  It  is  frequently  found  that  after  a 
pneumonia  has  run  its  course  the  temperature  remains  raised  a  degTee 
or  more  toward  evening.  Such  a  rise  in  temperature  may,  in  the 
absence  of  signs  of  fluid,  indicate  a  dry  plastic  pleurisy  (Fig.  131). 
On  the  other  hand,  if  there  are  signs  of  fluid  and  the  temperature- 
curve  shows  irregularities  of  rise,  emj^yema  may  be  present.  I  have 
seen  empyema  without  any  rise  of  temperature  in  infants  who  showed 
the  physical  signs  of  fluid  in  the  chest.  These  points  will  be  more 
fully  discussed  in  considering  Empyema. 

Pericarditis. — I  have  seen  pericarditis  in  infants  who  died  of  a 
fibrinous  pneumonia,  but  the  diagnosis  was  not  made  during  life. 
Von  Jaksch  notes  such  cases.  In  older  children,  pericarditis  is  a 
complication  found  in  cases  of  fibrinouspneumonia  which  have  simul- 
taneously developed  empyema.  Such  cases  are  very  uncommon.  In 
the  form  of  pericarditis  which  I  have  seen  in  infants,  the  quantity  of 
effusion  has  not  been  sufficiently  great  to  enable  a  diagnosis  to  be 
made  with  certainty,  and  the  rales  in  the  lung  obscured  the  friction- 
sounds  in  the  pericardium  if  they  were  present.  Purulent  pericar- 
ditis in  these  subjects  is  very  fatal  under  such  conditions.  In  older 
children  I  have  seen  pneumonia  combined  with  a  fibrinous  pericar- 
ditis pure  and  simple,  without  fatal  issue. 

Prognosis. — The  prognosis  of  lobar  pneumonia  varies  within  cer- 
tain limits.  Text-books  give  statistics  taken  from  hospital  cases, 
notably  the  most  unfavorable  material.  Henoch  gives  the  mortality 
of  his  cases  at  5  per  cent. ;  Baginsky,  at  S  per  cent. ;  Holt,  at  12  per 
cent. ;  my  own  hospital  cases  during  the  past  year  showed  a  mortality 
of  8  per  cent.  On  the  other  hand,  in  private  practice  death  from  an 
acute  fibrinous  pneumonia  rarely  occurs  in  a  child  previously  healthy 
and  living  in  good  surroundings. 

The  mortality  is  influenced  by  the  season  of  the  year,  being  greater 
from  December  to  February,  and  by  the  presence  of  an  epidemic.  If 
pneumonia  is  prevalent  during  an  epidemic  of  influenza,  the  mor- 
tality will  increase.  Pericarditis  or  complicating  empyema  influence 
the  death-rate.  The  previous  condition  of  the  patient,  the  mode  of 
feeding  (whether  by  the  breast  or  the  bottle),  and  a  rachitic  or  ma- 
rantic condition,  affect  the  prognosis.  The  age  of  the  patient  is  also 
an  important  factor.  Infants  under  one  3'ear  of  age  are  in  greater 
danger  than  older  ones.  The  prognosis  is  best  from  the  third  to  the 
tenth  year.     The  younger  the  bottle-fed  baby,  the  more  serious  the 


DISEASES    OF    THE   LUNGS.  629 

complication  of  empyema.  In  making  a  prognosis  in  any  concrete 
casie,  the  physician  should  be  guided  by  the  extent  of  lung  involve- 
ment and  the  general  condition  of  the  circulation.  If  one  lobe  alone 
is  involved  and  there  is  an  absence  of  bronchitis  in  the  unaffected 
lung,  the  outlook  is  good.  If  the  heart  action  is  good  and  there  is  an 
absence  of  cyanosis,  recovery  can  be  predicted  even  if  the  temperature 
be  high.  If,  on  the  other  hand,  the  lysis  or  crisis  is  delayed  and  the 
dulness  or  flatness  involves  a  whole  side  of  the  chest,  in  the  presence 
of  signs  of  a  weak  heart  the  prognosis  should  be  made  with  caution. 

Meningitis  is  grave.  I  have  seen  cases  of  meningococcus  menin- 
gitis which  complicated  pneumonia  recover,  but  pneumococcus  and 
streptococcus  meningitis  are  fatal.  Pericarditis  in  young  infants 
and  children  is  a  complication  invariably  fatal.  Where  facilities 
exist,  a  leucocyte-count  should  be  taken  every  second  day,  accom- 
panied by  a  differential  count  of  leucocytes.  A  very  low  leucocyte- 
count,  with  marked  signs  of  pneumonia  and  a  high  temperature,  is  a 
grave- prognostic  sign,  though  such  cases  may  recover.  On  the  other 
hand,  a  continued  high  leucocyte-count,  as  has  been  pointed  out,  may 
be  present  with  extensive  inflammation  of  both  lungs,  and  death 
may  ensue. 

Diagnosis.- — The  diagnosis  of  lobar  pneumonia  in  infancy  and 
childhood  ordinarily  presents  few  difficulties,  but  is  not  easily  made 
if  in  addition  to  the  pneumonia  there  is  an  effusion  in  the  chest.  The 
diagnosis  should  never  be  made  early  in  the  disease  without  positive 
signs. 

The  crepitant  rale  sometimes  escapes  observation.  The  physician 
should  then  wait  for  the  appearance  of  dulness  or  bronchial  voice  and 
breathing  before  arriving  at  a  conclusion  as  to  the  ]iresence  or  absence 
of  consolidation.  Cases  of  influenza  with  a  harassing  cough  are  fre- 
quently diagnosed  as  central  pneumonia.  A  pneumonia  which  is 
central  will  give  physical  signs  when  the  consolidated  area  approaches 
the  pleura.  If  after  the  time  set  for  the  crisis  or  lysis,  the  tempera- 
ture persists  and  becomes  remittent,  careful  examination  should  be 
made  for  evidences  of  fluid  in  the  chest.  The  nature  of  the  fluid 
should  be  determined  by  exploration  with  the  aspirating  needle,  if  the 
fever  does  not  subside  and  if  the  dyspnoea  increases.  A  chest  effu- 
sion in  infants  and  children  is  apt  to  be  purulent. 

The  cerebral  cases  present  difficulties  of  diagnosis.  Convulsions, 
delirium  and  rigidity  of  the  neck,  accompanied  by  high  fever  and  a 
cough,  with  increase  of  the  pulse-rate  and  the  number  of  respirations, 
indicate  the  necessity  of  making  a  very  careful  examination  of  the 
chest. 

In  cases  which  begin  with  a  lobar  pneumonia,  typhoid  fever  may 
be  suspected  if,  after  the  first  days  of  illness,  a  roseola  or  an  enlarge- 


630  DISEASES    OF    THE    BESPIRATOBY    SYSTEM. 

ment  of  the  spleen  develops  with  a  continuance  or  gradual  rise  of 
temperature.  In  such  cases  the  presence  of  an  epidemic  of  typhoid 
fever  and  the  Widal  blood  reaction  will  be  of  service  in  clearing  up 
the  diagnosis. 

Treatment. — The  treatment  of  lobar  pneumonia  is  pre-eminently 
expectant.  The  disease  is  self  limited,  and  complications  cannot  be 
prevented.  The  temperature  should  be  treated  within  certain  limits, 
and  the  heart  and  the  strength  of  the  patient  supported.  The  tem- 
perature should  be  treated  not  with  a  view  to  its  actual  reduction, 
but  in  order  to  mitigate  its  ill  effects.  Infants  and  children  will  be 
less  affected  by  a  temperature  of  103°  F.  (39.4°  C.)  during  a  pneu- 
monia than  by  the  same  temperature  in  typhoid  fever.  The  toxaemia 
of  pneumonia  is  of  a  more  benign  character. 

Hydrotherapy. — Sponging  is  efficient  in  cases  in  which  the  tem- 
perature does  not  generally  range  above  104°  or  104.5°  F.  (40°  C). 
The  younger  the  infant  the  less  energetic  need  it  be,  for  a  tempera- 
ture of  104.5^  F.  (40°  C.)  is  not  high  for  an  infant  under  two  years 
of  age.  I  content  myself  with  sponging  the  body  with  water  at  80° 
F.  (26.6°  C),  to  which  some  alcohol  has  been  added.  If  the  tem- 
perature remits  a  degree  or  more  during  the  twenty-four  hours,  there 
will  be  less  need  of  sponging.  The  temperature  should  never  be 
taken  more  often  than  every  three  hours.  If  it  is  above  103.5°  F. 
(39.7°  C),  the  patient  is  sponged  for  fifteen  minutes  and  then  given 
absolute  rest  for  three  hours.  Frequent  sponging  is  pernicious. 
Some  infants  when  sponged  with  water  at  80°  F.  (26.6°  C.)  become 
cyanosed,  with  rapid  and  thready  pulse.  With  these  patients  a  warm 
bath  at  a  temperature  of  105°  to  107°  F.  (40.5°  to  41.6°  C.)  is 
stimulating.  It  supports  the  strength  and  certainly  lessens  the  ill 
effects  of  the  temperature,  although  it  may  not  reduce  it  palpably. 
I  do  not  use  the  full  cold  bath  in  the  treatment  of  lobar  pneumonia  in 
infants  and  children.  If  the  temperature  reaches  105°-106°  F. 
(40.5°-41.1°  C),  a  full  bath  of  the  temperature  of  85°-90°  F. 
(29.4°~32.2°  C.)  or  higher  may  be  given,  certainly  never  lower. 

One  of  the  most  useful  methods  of  hydrotherapy  in  the  treatment 
of  pneumonia  in  young  infants  is  the  so-called  chest  compress.  These 
compresses  renewed  every  hour  will  cause  the  restlessness  to  diminish, 
the  heart  action  to  improve,  and  the  patient  to  fall  into  a  quiet  slum- 
ber. The  actual  reduction  of  temperature  is  not  so  marked  as  the 
favorable  effect  on  the  general  condition  of  the  patient.  The  appli- 
cation of  compresses  is  discontinued  if  the  temperature  falls  below 
103°  F.  (39.4°  C). 

Medicinal  Treatment. — The  licart  action  if  good  needs  no  atten- 
tion. At  most,  a  limited  amount  of  alcohol  in  form  of  wine  or 
whiskey  is  adiiiinislfi-ofl.      Infants  may  rof^oi\'c  half  a  drafhin   (2.0) 


DISEASES    OF    THE    LUNGS.  ^  631 

every  few  hours;  older  children,  a  drachm  (4.0).  Alcohol  should 
hot  be  given  as  a  routine  remedy.  If  the  temperature  is  high,  neces- 
sitating hydrotherapy,  and  the  pulse  is  above  120,  alcohol  should  be 
given.  If  the  pulse  is  high,  150-160,  a  few  minims  of  the  tincture 
of  digitalis  may  be  given  to  older  children.  Younger  children  rarely 
need  more  than  half  a  minim  every  two  or  three  hours.  If  the  pulse- 
rate  is  reduced  after  the  administration  of  digitalis,  the  drug  should 
be  discontinued  before  the  pulse  drops  below  100.  There  is  no  doubt 
that  its  effect  is  more  cumulative  in  some  subjects  than  in  others. 

Strychnine  is  of  value  in  the  treatment  of  pneumonia,  not  so 
much  in  the  cases  with  rapid  as  in  those  with  slow  and  irregular 
pulse.  Infants  will  bear  grain  Hoo  to  M.50  (0.0003  to  0.0004)  every 
three  hours,  for  days. 

Caffeine  is  of  great  value  in  the  treatment  of  irregularities  of  the 
heart  which  indicate  a  myocarditic  toxsemia.  The  pain  is  the  result 
of  a  pleuritic  process. 

The  local  application  of  iodine  or  mustard  paper  is  an  efficient 
counter-irritant.  If  the  cough  is  troublesome,  codeine  in  moderate 
dosage  is  the  most  useful  remedy. 

I  do  not  use  morphine  with  infants  and  children.  In  young 
infants  the  milder  preparations  of  opium,  such  as  camphorated  tinc- 
ture or  the  wine,  are  more  useful.  Four  minims  (0.25)  of  the  cam- 
phorated tincture  of  opium  every  two  or  three  hours  will  be  found 
efficient  in  children  under  two  years  of  age.  To  older  children  a  small 
dose  of  codeia  may  be  given  several  times  daily  if  needed.  The  aim 
is  to  alleviate,  not  abolish,  the  pain  and  cough. 

The  bowels  should  be  evacuated  daily ;  for  this  purpose  hydrarg. 
cum  creta  is  one  of  the  best  remedies.  Grain  v  (0.3)  may  be  given. 
Infants  should  receive  an  enema  daily.  If  gastro-enteric  disturb- 
ances are  present,  milk  should  be  discontinued,  broths  substituted  and 
the  same  procedure  followed  as  in  primary  gastro-enteritis. 

Tympanites  is  sometimes  troublesome,  especially  in  young  chil- 
dren. The  best  remedy  is  a  high  enema  twice  daily  of  salt  solution, 
to  which  one  or  two  teaspoonfuls  of  peppermint-water  have  been 
added.  The  passage  of  a  soft  catheter  is  not  effective,  nor  are  the 
turpentine  stupes  of  any  value.  Milk  should  be  eliminated  tempo- 
rarily from  the  diet. 

The  delirium,  sometimes  amounting  to  an  acute  mania,  which 
appears  just  before  the  crisis  in  some  cases,  is  best  controlled  by 
rectal  administration  of  bromide  of  potassium  and  chloral  hydrate. 
I  have  sometimes  been  forced  to  keep  the  patient  under  the  influence 
of  these  drugs  for  a  few  days.  The  post-pneumonic  melancholia 
seen  in  children  is  best  treated  by  the  administration  of  strychnine 
and  the  enforcement  of  perfect  quiet. 


632  DISEASES    OF    THE    EESPIBATOEY    SYSTEM. 

Should  signs  of  extreme  cardiac  Tvc-akness  set  in  with  threatening 
oedema  of  the  lung  and  paralysis  of  the  right  ventricle,  nitroglycerin 
is  of  great  value.  Infants  will  bear  grain  /4oo  (0.0003)  every  three 
hours.  If  in  these  cases  cyanosis  is  present,  oxygen  is  administered, 
preferably  that  containing  20  per  cent,  of  nitrous  oxide.  It  is  given 
to  infants,  every  half  hour  for  five  or  ten  minutes  at  a  time  by  means 
of  a  cone. 

Hygiene. — The  patient  should  be  isolated  if  possible.  The  room 
should  be  ventilated  and  its  temperature  kept  at  68°— 72°  F.  (20'- 
22.2°  C). 

The  sputum  should  be  received  in  pieces  of  gauze,  which  are 
burned.  The  mouth  and  teeth  should  be  cleansed  twice  daily  with 
a  piece  of  soft  linen  and  a  solution  of  boric  acid.  In  the  intervals 
between  feedings  the  tongue  is  kept  moist  by  frequent  draughts  of 
water. 

Bronchopneumonia  ( C  atarrlial  Ptieumonia,  Lobular  Pneumonia^ . 
— Bronchopneumonia  is  the  prevalent  type  of  pneumonia  occurring 
before  the  fifth  year,  but  many  cases  of  lobar  fibrinous  pneumonia 
are  seen  during  infancy  and  early  childhood. 

Occurrence. — Bronchoj)neumonia  occurs  both  as  a  primary  and  a 
secondary  disease.  As  a  primary  disease  it  is  most  frequent  during 
the  first  two  years  of  life.  Of  605  of  my  cases  of  bronchopneumonia, 
the  incidence  in  regard  to  age  was  as  follows : 

Cases. 

One  to  three  months 32 

Three  to  six  months 68 

Six  to  twelve  months 207 

One  to  two  years 298 

These  figures  correspond  within  certain  limits  to  those  of  other 
observers,  although  Holt  places  the  greatest  frequency  between  the 
sixth  and  the  twelfth  months. 

Sex. — Of  the  605  cases,  322  were  males — a  statement  correspond- 
ing to  that  of  Jiirgensen  in  regard  to  lobar  pneumonia. 

Season. — The  greatest  frequency  is  during  the  winter  months, 
when  there  are  epidemics  of  influenza  dtiring  which  many  primary 
and  secondary  cases  of  bronchopneumonia  occur. 

Surroundings. — The  herding  together  of  the  poor  certainly  has 
a  tendency  to  increase  the  prevalence  of  bronchopneumonia  among 
them.  If  we  believe  in  the  epidemiological  aspects  of  pneumonia,  it 
is  easy  to  account  for  the  greater  frequency  of  the  disease  among  the 
poor :  the  gi'eater  number  of  their  children  are  rachitic,  syphilitic, 
marantic,  and  ill-fed,  and  thus  have  increased  susceptibility  to  in- 
fection. 

Secondary  bronchopneumonia   occurs   as   a   complication   in   the 


DISEASES    OF    THE    LUNGS.  633 

exanthemata  (measles,  scarlet  fever,  typhoid  fever),  diphtheria,  per- 
tussis, and  influenza.  By  far  the  greater  number  of  cases  occur  as 
a  sequence  of  ordinary  bronchitis. 

Etiology  and  Bacteriology. — Weichselbaum  first  d'^monstrated  that 
the  pneumococcus  of  Frankel  could  cause  primary  bronchopneumonia. 
His  results  have  been  confirmed  by  Cornil,  Babes,  and  Neumann,  the 
latter  of  v^^hom  found  the  pneumococcus  in  cases  of  primary  broncho- 
pneumonia. Quesiner  and  Neumann  found  the  pneumococcus  in  the 
sputum  of  children  suffering  from  bronchopneumonia. 

The  secondary  form  of  bronchopneumonia  may  be  caused  by 
streptococci  (Northrup  and  Prudden),  v^hich  invade  the  lung-tissue 
from  the  trachea,  as  in  diphtheria.  Guarnieri  also  found  strepto- 
cocci in  the  lungs  of  children  dying  with  bronchopneumonia  after 
measles.  On  the  other  hand,  these  secondary  types  of  bronchopneu- 
monia may  also  be  caused  by  the  pneumococcus  of  Frankel,  which  is 
an  etiological  factor  in  the  primary  type  of  the  disease.  This  has 
been  shown  in  the  work  of  Netter  on  the  subject,  and  confirmed  by 
Banti,  Strelitz,  and  Baginsky.  In  diphtheria  the  Klebs-Loffler  ba- 
cillus may  be  found  in  the  lung  areas  of  secondary  bronchopneumonia 
(Babes,  Frosch,  Baginsky).  The  Eberth  bacillus  has  been  found  in 
areas  of  bronchopneumonia  complicating  typhoid  fever  (Polyniere). 

Morbid  Anatomy. — The  essential  lesion  in  bronchopneumonia  is 
an  inflammation  of  the  walls  of  the  bronchi  and  of  the  air-spaces  sur- 
rounding the  inflamed  bronchi  (Delafleld).  The  walls  of  the  bronchi 
are  thickened  and  infiltrated  with  small  round  cells ;  those  of  the 
alveoli  of  the  lung  are  thickened  and  their  cavities  filled  with  fibrin, 
pus,  epithelial  cells,  and  new  connective  tissue.  The  smaller  bronchi 
are  dilated  and  contain  pus,  their  walls  being  infiltrated.  The  in- 
flammation may  also  be  conveyed  from  the  bronchi  to  the  paren- 
chyma of  the  lung  by  aspiration  of  secretion  (Ziegler).  In  the  latter 
case  the  smaller  bronchi  are  occluded,  collapse  of  the  lung  follows 
(atelectasis),  and  a  pneumonia  thus  results.  On  section  there  are 
seen  grayish-red,  gray,  or  yellowish-gray  areas  of  varying  consistency, 
which  correspond  to  a  cut  bronchus  and  its  surrounding  peribron- 
chitic  pneumonia. 

If  the  areas  are  croupous,  they  have  a  more  granular  appearance. 
Small  areas  of  this  form  of  pneumonia  may  coalesce,  and  thus  whole 
lobules  of  the  lung  may  be  consolidated.  These  larger  areas  may  be 
separated  by  lung-tissue  which  contains  air,  or  a  whole  lobe  may  be- 
come consolidated,  as  in  lobar  pneumonia.  The  exudate  found  in  the 
affected  alveoli  is  at  flrst  composed  of  desquamated  swollen  epithelial 
cells,  and  later  of  leucocytes.  If  the  exudate  has  a  more  fluid  char- 
acter, it  is  called  catarrhal.  It  then  contains  more  serum  than  fibrin. 
Jf  the  fibrin  is  in  excess,  the  exudate  has  greater  consistency,  resem- 


634  DISEASES    OF    THE    EESPIEATOEY    SYSTEM. 

bling  that  of  lobar  pneumonia,  and  is  then  called  croupous.  The 
catarrhal  and  croupous  forms  of  exudate  may  both  exist  in  a  lung 
affected  with  bronchopneumonia.  Blood-cells  mav  predominate  in 
the  exudate,  so  that  the  lung  may  on  section  have  a  hemorrhagic 
appearance.  This  is  apt  to  be  the  case  in  streptococcus  inflammation 
and  also  if  foul  fluids  have  been  aspirated. 

The  mucous  membrane  of  the  bronchi  is  the  seat  of  catarrhal 
inflammation. 

There  is  inflammation  of  the  pleura  to  a  varying  degree. 

The  bronchial  and  mediastinal  lymph-nodes  may  be  enlarged. 
There  is  oedema  of  the  lung  tissue  which  is  not  inflamed.  Broncho- 
pneumonia may  result  in  resolution  and  restoration  to  the  normal. 
Suppuration  and  formation  of  abscess  with  destruction  of  lung  tissue, 
or  gangrene  of  the  lung,  may  result  in  rare  cases. 

Persistent  bronchopneumonia  in  children  leads  to  induration  of 
the  lung.  There  is  an  increase  of  the  connective  tissue  of  the  alveolar 
septa,  of  the  walls  of  the  smaller  and  larger  bronchi,  and  also  of  the 
walls  of  the  peribronchial  vascular  tissue.  The  lung  on  section  is 
seen  to  be  studded  with  fibrous  nodules,  or  a  whole  lobule  or  lobe  may 
be  converted  into  connective  tissue. 

Symptoms. — Bronchopneumonia  is  divided  clinically  into  several 
distinct  types.  In  newly  born  and  very  young  infants  the  disease 
may  set  in  insidiously.  The  infant  is  born  in  normal  condition: 
after  some  little  exposure  it  develops  slight  snuffles  and  a  slight  cough. 
Dyspnoea  then  appears.  All  this  may  occur  within  the  first  eight 
days  after  birth.  The  cough  becomes  more  harassing  and  the  dyspnoea 
more  marked.  Slight  cyanosis  supervenes  after  a  time.  The  infant 
is  restless  and  does  not  sleep,  the  cyanosis  becoming  more  marked  and 
constant.  The  infant  may  have  frequent  convulsions.  The  dyspnoea 
finally  becojmes  so  marked  as  to  cause  distinct  drawing  inward  of  the 
lower  part  of  the  chest-wall  with  each  inspiration.  In  these  cases 
there  is  little  or  no  temperature ;  in  that  respect  they  resemble  cases 
of  bronchopneumonia  in  extremely  old  people. 

The  temperature  may  be  slightly  subnrjrmal  even  when  the  infant 
is  mortally  ill  with  a  disseminated  bronchopneumonia.  The  cough 
may  nrjt  be  marked.  These  cases  should  be  differentiated  from  those 
occurring  in  infants  born  with  an  atelectatic  crjndition  of  the  lungs. 
In  the  class  of  cases  under  consideration,  atcdectasis  develops  as  a 
sequence  of  the  bronchitis  and  bronchopneumonia.  The  movements 
are  greenish,  cotntaining  undigested  curds.  The  infants  may  finally 
develop  enteritis.  The  course  of  the  disease  is  in  these  cases  very 
acute.  The  infant  either  rapidly  grows  worse  or  begins  to  improve 
immediately.  The  former  conrse  is,  however,  the  rule  in  this  very 
dangerous  and  insidious  form  of  bronchopneumonia.     If  the  infant 


DISEASES    OF    THE    LUNGS.  635 

does  not  improve,  the  cyanosis  becomes  more  marked,  as  does  also  the 
dyspnoea;  the  respirations  increase  to  more  than  80  a  minute,  the 
pulse  becomes  very  rapid,  and  the  heart  feeble ;  the  infant  lies  in  a 
soporose  state;  the  end  may  supervene  with  tympanites,  convulsions, 
and  oedema  of  the  lung.  This  form  of  bronchopneumonia  is  very  fre- 
quently overlooked  at  the  outset  and  mistaken  for  a  simple  bronchitis. 

Another  form  of  bronchopneumonia  in  infancy  begins  as  a  simple 
bronchitis,  and  may  be  treated  as  such  for  days.  Finally,  posteriorly 
in  both  lungs  there  are  found  the  fine  crepitations  which  give  warning 
of  the  presence  of  bronchopneumonic  processes.  Bronchopneumonia 
of  this  variety  runs  its  course  without  temperature.  It  occurs  in 
rachitic  or  weakly  infants  and  children,  or  follows  a  mild  attack  of 
influenza.  The  attacks  of  coughing  are  especially  troublesome,  and 
are  frequently  followed  by  vomiting  of  the  contents  of  the  stomach. 
The  movements  are  loose,  and  show  greenish  particles  and  undigested 
white  flaky  masses.  The  dyspnoea  is  constant  and  characteristic,  and 
if  the  patient  is  out  of  bed,  grows  more  marked  toward  the  late  after- 
noon. The  alse  nasi  are  dilated.  The  temperature  rarely  rises  above 
101°  F.  (38.3°  C),  and  is  generally  100°  F.  (37.2°  C.)  or  even 
lower.  The  cough  may  persist  for  weeks  after  the  subsidence  of  the 
acute  symptoms,  being  especially  marked  at  night. 

A  more  common  form  of  bronchopneumonia  in  infancy  begins 
as  a  simple  bronchitis,  which  may  last  for  a  few  days,  when,  without 
warning,  the  infant  has  a  chill  followed  by  a  rise  of  temperature,  the 
case  having  suddenly  developed  into  a  full  bronchopneumonia.  In  a 
six  weeks'  old  infant  with  disseminated  patches  of  pneumonia,  the 
chill  was  so  severe  as  to  cause  extravasations  of  blood  underneath  the 
surface,  with  markings  resembling  those  seen  in  marbling  of  the  sur- 
face. In  another  case  the  chill  was  so  severe  that  an  immediate 
fatal  issue  was  feared.  In  that  bronchopneumonia  sometimes  begins 
with  a  chill,  it  resembles  a  lobar  process. 

The  most  common  type  of  bronchopneumonia  may  begin  with  a 
rise  of  temperature  preceded  by  vomiting.  The  harassing  cough  is 
present  from  the  outset,  causing  the  patients  to  cry  with  pain  at  each 
attack.  There  is  no  sputum,  but  in  very  young  infants  a  frothy 
mucus  may  in  the  later  stages  of  the  disease  collect  about  the  lips. 
The  dyspnoea  is  marked.  The  alte  nasi  are  dilated  at  each  inspira- 
tory effort.  The  peripneumonic  groove  is  retracted  and  in  very 
severe  dyspnoea  the  suprasternal  region  may  also  be  depressed  at  each 
inspiration.  Very  frequently  the  dyspnoea  will  resemble  that  due  to 
laryngeal  stenosis.  There  are,  however,  none  of  the  signs  of  laryn- 
geal obstruction,  such  as  laryngeal  breathing. 

Fever. — Fever  is  always  present  in  infants  and  children,  except 
in  the  classes  of  cases  above  noted.     It  may  reach  106°  F.   (41.1° 


636 


DISEASES    OF    THE    EESPIBATOBT    SYSTEM. 


C),  and  is  as  a  rule  remittent.  It  may  fall  gradually  to  the  normal, 
and  in  the  favorable  cases  may  reach  the  subnormal  and  remain  there 
for  a  few  days.  The  course  of  the  fever  is.  however,  not  an  indica- 
tion of  the  severity  of  the  disease.  Fatal  bronchopneumonia  some- 
times shows  a  steady  decline  in  the  temperature  toward  the  approach 
of  the  fatal  issue.  In  other  cases  the  temperature  may  drop  to  the 
normal,  remain  there  a  few  hours  or  a  day.  and  then  rise  sharply  to 
104°  F.  (40°  C.)  or  higher,  thus  indicating  that  a  new  area  of  the 
lung  has  been  invaded  by  the  disease  (Fig.  132).  Such  rises  of 
temperature  after  a  fall  to  the  normal  are  of  grave  import  if  they 
occur  in  an  infant  acutely  ill  with  a  process  which  has  been  severe 
for  days.  They  show  a  tendency  of  the  process  to  spread,  and  in 
young  weakly  infants  such  an  extension  of  the  process  is  apt  to  be 

Fig.  132. 


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Fatal  bronchopneumonia  ;   reinvasion  of  the  lung  on  the  fifth  day.       Infant,  six  months  old. 

fatal.  A  drojD  by  lysis  to  a  normal  temperature  which  continues  for 
a  few  days,  and  is  followed  by  a  slight  gradual  rise  with  subsequent 
remissions  to  the  normal,  is  also  common,  and  may  indicate  a  return 
of  the  bronchopneumonia  process,  or  a  pleuritic  effusion  of  a  puru- 
lent character.  The  physician  should  be  on  the  alert  for  an  eifusion 
in  the  cases  which  have  run  an  irregular  or  remittent  temperature 
for  a  period  of  more  than  two  weeks.  I  have,  however,  operated  upon 
cases  of  empyema  following  bronchopneumonia  in  infants,  in  which 
the  temperature-curve  was  normal  for  days,  and  then  showed  occa- 
sional rises  to  101°  or  102°  F.  (38.3°  or  38.8°  C). 

Pulse. — The  pulse  is  as  a  rule  rapid.  It  is  difficult  in  infants  to 
estimate  its  exact  character.  It  is,  however,  always  possible  to  dis- 
tinguish the  abnormally  weak  and  thready  pulse  even  in  the  youngest 
infant.  The  rapidity  of  the  pulse  varies  widely  even  in  the  favorable 
cases.  Its  ratio  to  the  respiration  (the  pulse-respiration  ratio)  is,  as 
a  rule,  maintained  in  favorable  cases.  Even  if  it  be  so  much  dis- 
torted as  to  present  the  ratio  of  1  to  2,  the  patient  may  make  a  good 


DISEASES    OF    THE    LUNGS. 


637 


rccoverj.  The  character  of  the  pulse  and  respiration  should  there- 
fore be  judged  in  connection  with  other  signs  of  decreasing  heart 
jxiwer,  such  as  abnormal  pallor,  coldness  of  the  surface,  and  cyanosis, 
huwever  slight.  In  artificially  fed  infants  who  are  above  the  average 
weight,  the  beginning  of  cardiac  weakness  is  indicated  by  an  abnormal 
pallor  of  the  face  and  slight  cyanosis  of  the  lips. 

Sputum. — In  3'oung  infants  there  is  no  sputum,  nor  is  it  probable 
that  in  uncomplicated  cases  of  bronchopneumonia  the  younger  infants 
cough  up  and  swallow  sputum,  as  is  generally  supposed.  At  most, 
there  is  after  severe  attacks  of  coughing  a  collection  about  the  lips  of 
frothy  mucus,  probably  coming  from  the  trachea. 

Fig.  133. 


Ordinary  type  of  bronchopneumonia.     Recovery.     Female  child,  one  year  and  six 

months  of  age. 


Gastro-enieric  Tract. — The  symptoms  referable  to  the  stomach 
and  intestine  are  of  great  importance  in  severe  bronchopneumonia  of 
the  primary  type.  Even  up  to  the  second  year  of  life  tympanites 
sets  in  very  early.  It  may  mislead  the  physician  into  thinking  that 
peritonitis  might  be  present.  It  is  especially  apt  to  set  in  with 
rachitic  and  weakly,  artificially  fed  infants.  It  is  appears  late  in 
a  very  sick  infant,  it  is  a  symptom  of  grave  import,  and  may  some- 
times cause  the  fatal  issue.  In  some  cases  the  pre-agonal  distention 
is  very  great,  and  so  far  as  can  be  judged  painful.  Some  infants 
begin  to  vomit  from  the  outset  of  the  pneumonia.  The  vomiting  may 
occur  once  or  twice  in  the  twenty-four  hours,  or  may  be  incessant. 
With  the  vomiting  there  may  be  the  passage  of  greenish  stools  or  a 
fully  developed  enteritis  of  severe  type.  So  severe  is  the  enteritis  in 
some  cases  as  to  cause  the  death  of  a  patient  suffering  from  pneu- 
monia of  only  moderate  severity.  This  form  of  the  disease  does  not 
occur  exclusively  in  the  summer  months,  but  is  more  prevalent  at 
that  time. 


638  DISEASES    OF    THE    BESPIEATOEY    SYSTEM. 

Cerebral  Symptoms. — The  infant  is  in  some  cases  stupid  from 
the  outset  of  the  disease.  Older  children  mav  have  slight  convulsive 
twitchings  of  the  muscles  of  the  face  and  extremities.  In  some  cases 
in  children  in  the  third  year  there  may  he  complete  unconsciousness 
and  symptoms  simulating  those  of  meningitis,  such  as  rigidity  of  the 
muscles  of  the  neck.  I  have  seen  the  cerebral  symptoms  persist  for 
weeks  in  young  infants  v^^ho  made  complete  recoveries.  In  other 
cases,  the  bronchopneumonia  may  partly  resolve,  and  still  there  may 
be  a  continuance  of  the  cerebral  symptoms  or  even  an  exacerbation 
of  them.  In  these  eases  the  possibility  of  the  presence  of  otitis  or 
mastoid  inflammation  should  be  seriously  considered. 

The  secondary  form  of  bronchopneumonia  may  complicate  the 
exanthemata — measles,  scarlet  fever,  varicella,  typhoid  fever,  per- 
tussis, influenza,  and  dij)htheria,  and  also  gastro-enteritis  or  any  form 
of  infection,  such  as  that  of  septic  wounds  or  osteomyelitis. 

Pertussis. — The  symptoms  of  bronchopneumonia  which  compli- 
cates pertussis  are  of  an  unequivocal  character.  A  febrile  movement 
may  be  present  with  a  simple  bronchitis.  If  bronchopneumonia  is 
imminent  or  present,  the  fever  is  marked  and  constant,  and  may 
reach  106°  F.  (41.1°  C).  The  dyspnoea  is  very  marked,  but  the 
cough  may  not  be  increased.  In  certain  forms  of  pertussis  without 
complications  there  is  a  slight  constant  dyspnoea,  which  is  due  to  the 
disease.  If  bronchopneumonia  is  a  complication  the  dyspnoea  is  more 
decided,  the  number  of  respirations  three  or  four  times  the  normal, 
and  the  pulse-rate  increased.  There  is  marked  cyanosis.  There  may 
be  all  the  symptoms  of  a  severe  bronchopneumonia,  such  as  tympa- 
nites, vomiting,  and  green  diarrhceal  stools.  The  bronchopneumonia 
is,  as  a  rule,  of  the  disseminated  type,  with  areas  of  consolidation  of 
greater  or  lesser  extent  in  both  lungs.  The  infants  are  much  more 
ill  than  they  would  be  with  a  primary  process  of  the  same  extent. 
A  bronchopneumonia  of  this  kind  can  be  diagnosed  if  upon  exami- 
nation there  are,  in  addition  to  the  physical  signs  of  bronchitis,  fine 
crepitations  over  the  different  parts  of  the  chest,  especially  over  the 
lower  lobes  of  both  lungs  posteriorly.  There  may  also  be  dulness 
with  bronchophony  and  bronchial  breathing  over  small  areas,  either 
in  the  upper  or  lower  lobes  of  the  lung  on  one  or  both  sides. 

The  bronchopneumonia  of  pertussis  may  supervene  at  any  period 
of  the  disease,  and  is  not  the  result  of  exposure.  On  the  contrary,  it 
may  occur  in  infants  and  children  who  have  been  most  carefully  pro- 
tected from  exposure.  It  is  the  result  of  the  type  of  disease — a 
mixed  infection.  The  pertussis  probably  makes  the  lung  more  liable 
to  disease  in  some  subjects  than  in  others.  The  bronchopneumonia 
is  a  grave  complication,  and  is  very  fatal.  It  may  cause  complica- 
tions, such  as  pleurisy  of  a  serous  or  purulent  nature,  and  often  opens 


DISEASES    OF    TEE    LUNGS.  639 

the  way  for  invasion  of  the  lung  bj  tuberculosis.  It  may  run  a 
chronic  course  (persistent  pneumonia)  and  reduce  the  patient  to  a 
very  weak  state.  The  patient  will  then  develop  consolidation  of  a 
whole  lobe  of  the  lung  which  will  take  weeks  to  clear  up. 

Measles. — Bronchopneumonia  complicating  measles  supervenes, 
as  a  rule,  in  the  stage  of  eruption,  and  is  a  very  serious  complication. 
Its  presence  may  be  suspected  if,  on  examination  of  the  chest,  there 
are  found,  in  addition  to  the  rales  of  bronchitis,  very  fine  crepitant 
rales  over  areas  disseminated  through  both  lungs.  This  complication 
also  causes  a  febrile  movement  after  the  fading  of  the  eruption  and 
repeated  severe  chills  with  every  new  area  of  the  lung  involved. 
There  are  severe  cough  and  dyspnoea.  The  pulse  may  reach  180  to 
190,  and  the  respirations  90,  but  the  patient  may  recover  even  if  the 
signs  of  cardiac  weakness,  such  as  cyanosis,  are  marked.  The  patient 
is  stupid,  does  not  take  food  or  notice  his  surroundings.  Sometimes 
there  may  be  other  signs,  such  as  hemorrhages  into  the  eruption  (so- 
called  hemorrhagic  measles),  indicating  that  the  process  is  one  in 
which  there  is  a  mixed  infection.  There  may  be  a  complication  of 
serous  or  seropurulent  pleurisy. 

Typhoid  Fever. — Bronchopneumonia  complicating  typhoid  fever 
does  not,  as  a  rule,  give  very  striking  features  apart  from  those  be- 
longing to  the  latter  disease.  It  seems  to  be  of  a  mild  and  insidious 
character.  The  bronchopneumonia  of  typhoid  fever  is  apt  to  mask 
the  typhoid  if  it  appears  at  the  outset  of  the  disease.  There  is  then 
a  typhoid  beginning  as  a  pneumonia.  The  area  of  bronchopneumonia 
is  well  localized.  It  may  be  a  small  area  in  the  upper  or  mid-region 
of  the  lung.  The  febrile  curve  in  these  cases  may  range  quite  high 
at  the  outset  and  thus  mislead  the  physician.  The  process  persists 
for  weeks,  sometimes  as  long  as  five  weeks.  The  lung  is  slow  in 
clearing  up.  The  signs  of  dulness,  bronchial  voice  and  breathing  may 
persist  into  convalescence.  In  other  cases  the  pneumonia  may  super- 
vene in  the  course  of  the  disease.  It  can  then  be  detected  only  if 
the  cough  is  harassing  and  the  dyspna-a  marked.  In  delirious  pa- 
tients the  pneumonia  can  only  be  discovered  by  repeated  and  constant 
examination  of  the  chest.  These  cases  are  not  so  apt  to  develop 
pleurisy  of  a  serous  or  purulent  nature  as  the  pneumonia  complicat- 
ing measles  or  scarlet  fever. 

Varicella. — Varicella  is  only  rarely  complicated  by  bronchopneu- 
monia. In  this  disease  also  the  pneumonia  runs  a  protracted  course, 
but  is  less  serious  in  its  outcome  than  in  the  other  exanthemata.  It 
occurs  in  the  severer  forms  of  varicella  in  which  the  eruption  is  com- 
plicated with  abscesses  or  necrosis  of  the  skin  (mixed  infection). 

Scarlet  Fever. — Scarlet  fever  is  not  so  frequently  complicated  by 
bronchopneumonia  as  measles,  but  when  it  does  occur  the  broncho- 


640  DISEASES    OF    THE    EESPIEATOEY    SYSTEM. 

pneumonia  is  of  a  very  severe  type.  It  occurs  in  the  septic  forms  of 
scarlet  fever,  and  may  appear  early  in  the  disease,  on  the  fading  of 
the  eruption.  Scarlet  fever  complicated  by  bronchopneumonia  is 
frequently  followed  by  pleurisy  of  a  purulent  nature. 

Diphtheria. — ^The  bronchopneumonia  which  complicates  diph- 
theria has  been  carefully  studied  by  Northrup  and  Prudden.  It  is 
the  result  of  a  streptococcic  invasion  of  the  lung  or  an  invasion  by 
the  EHebs-Loffler  bacillus.  As  a  rule,  however,  it  is  a  mixed  infec- 
tion, as  was  pointed  out  by  ISTorthrup  and  Prudden.  The  laryngeal 
form  of  diphtheria  frequently  proves  fatal  through  this  complication. 

Diarrhceal  Condiiions. — Of  special  interest  is  the  bronchopneu- 
monia which  complicates  chronic  or  subacute  diarrhoeal  conditions. 
This  form,  which  is  of  a  distinctly  septic  type,  is  caused  by  infection 
of  the  lung  by  streptococci,  which  invade  the  general  circulation 
through  erosions  in  the  mucous  membrane  of  the  gut  (Booker,  Czerny, 
Fischl) .  It  is  not  always  due.  as  was  formerly  supposed,  to  keeping 
the  infant  in  the  recumbent  posture,  nor  does  it  occur  in  hospital 
practice  alone,  but  is  frequently  seen  in  private  practice  in  infants  in 
unhygienic  surroundings.  It  is  of  the  persistent  type,  and  runs  its 
course  with  a  daily  high  or  low  febrile  curve,  and  results  in  areas  of 
consolidation,  which  sometimes  involve  a  whole  lobe  of  a  lung.  This 
form  of  pneumonia  is  one  of  the  fatal  complications  of  the  subacute 
intestinal  catarrhs. 

Some  infants,  after  one  attack  of  bronchopneumonia,  have  re- 
peated or  recurrent  attacks  on  the  least  exposure  (Fig.  134),  in  some 
cases  developing  catarrhal  croup.  In  other  cases,  there  develops  an 
emphysematous  condition  of  the  lung,  in  which  the  least  exposure  or 
change  in  the  atmosphere  will  cause  an  asthmatic  attack. 

Course,  Termination,  and  Complications.- — Bronchopneumonia  may 
terminate  in  complete  recovery  and  restoration  of  the  lung  to  the 
normal,  or  may  prove  fatal.  The  mortality  varies  at  different  times 
and  with  the  environment.  The  prognosis  in  marantic  infants,  and 
also  in  bottle-fed  infants,  is  very  bad.  Rachitic  infants  have  bron- 
chopneumonia with  a  very  protracted  course  (Fig.  135).  The  forms 
which  complicate  measles,  pertussis,  scarlet  fever,  and  infltienza  are 
very  fatal.  Abscess  or  gangrene  of  the  lung  may  be  a  complication. 
In  some  forms  of  otitis  the  symptoms  may  very  closely  simulate  those 
of  tuberculous  meningitis.  Otitis  prolongs  the  disease  and  frequently 
misleads  the  physician.  Especially  trying  are  the  forms  of  broncho- 
pneumonia of  very  limited  extent  in  one  or  both  lungs,  in  which  there 
is  a  protracted,  remittent  or  intermittent  fever-curve.  Serous  pleu- 
risy and  empyema  are  very  common  complications.  Their  presence 
may  be  suspected  if  the  disease  runs  a  course  protracted  beyond  two 
weeks,  and  if  signs,  such  as  dulness,  flatness,  and  bronchophony,  per- 
sist and  become  more  marked  over  the  whole  side  of  the  chest. 


DISEASES    OF    THE    LUNGS. 


641 


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642  DISEASES    OF    THE    SESPII^AIOEY    SYSTEM. 

Meningitis. — ^Meningitis  may  complicate  the  disease.  Care  should 
be  taken  not  to  confound  cerebral  symptoms  with  true  meningitis. 

Pericarditis.  —  Pericarditis  comi^licating  bronchopneumonia  is 
apt  to  be  purulent,  and  is  rarely  diagnosed  during  life.  I  have  seen 
cases  in  which  during  life  repeated  examinations  failed  to  reveal 
positive  signs  of  eifusion  into  the  pericardium,  but  in  which  purulent 
pericarditis  was  found  at  autopsy.  This  is  frequently  true  of  cases 
in  which  the  effusion  is  limited  (30-50  grammes).  If  bronchopneu- 
monia occurs  in  the  left  lung  with  consolidation  anteriorly  and  some 
pleural  effusion,  it  is  almost  impossible  to  diagnose  moderate  peri- 
cardial effusion.     The  complication  is  very  fatal. 

Osteomyelitis. — Pfisterer  has  recently  published  a  number  of  cases 
of  pneumococcus  osteomyelitis  and  metastases  occurring  by  way  of 
the  blood  or  lymph-stream.  In  some  cases  the  arthritis  may  precede 
the  pneumonia ;  in  others,  may  follow  it.  The  portals  of  infection 
include  the  tonsil,  among  others  the  mouth  or  nose,  the  ear  or  peri- 
toneum. Traumatism  may  be  a  predisposing  factor.  J^etter  found 
3  of  arthritis  in  1218  cases  of  pneumonia.  It  is  therefore  rare  as 
compared  to  other  complications  of  pneumonia,  such  as  otitis  or  men- 
ingitis. I  have  seen  one  case  in  a  newborn  infant,  the  subject  of 
congenital  syphilis,  with  bronchopneumonia  of  a  syphilitic  character. 
In  this  case  the  hip-joint  was  the  seat  of  pneumococcus  suppuration. 
I  have  since  seen  a  number  of  cases  of  pneumococcus  arthritis  in  in- 
fants. As  a  rule,  the  larger  joints,  the  shoulder  or  knee,  are  affected. 
It  is  generally  monarticular,  but  may  be  polyarticular.  The  symptoms 
in  some  cases  escape  observation ;  in  others,  the  symptoms  are  similar 
to  those  of  osteomyelitis  with  arthritis.  If  the  arthritis  is  very  acute 
and  other  organs  are  involved,  death  may  result ;  but,  on  the  other 
hand,  if  the  joint  is  evacuated  in  time,  recovery  may  take  place. 
The  pneumococcus  arthritis  involves  the  tissues  surrounding  the 
joints.  The  cartilages  of  the  joint  are  rarely  involved.  Pneumo- 
coccus osteitis  affects  the  cortical  layers  of  the  bone  in  the  vicinity 
of  the  epiphyseal  line.  Large  sequestra  are  rare.  Of  41  cases,  15 
occurred  in  childhood  in  the  first  two  years  of  life. 

Of  44  cases  of  pneumococcus  arthritis  and  osteitis  collected  by 
Pfisterer,  23  died.  Death  was  due  to  pneumonia,  empyema,  menin- 
gitis, endo-  or  pericarditis. 

Physical  Signs. — Clinically  the  physical  signs  of  broncho]uieu- 
monia  are  divided  in  those  of  the  following  stages:  the  first  stage — • 
invasion ;  the  second  stage — consolidation ;  the  third  stage — resolu- 
tion. There  is  no  sharp  line  of  demarcation  between  the  signs  of 
the  stages. 

First  Stage. — Inspection  shows  the  face  to  be  flushed  on  one  or 
both  sides,  and  the  nostrils  to  be  dilated ;  with  each  inspiration  there 


DISEASES    OF    THE    LUNGS.  643 

is  drawing  inward  of  the  peripneiimonic  groove  and  sometimes  of  the 
suprasternal  tissues  over  the  upper  joart  of  the  trachea. 

If  bronchitis  is  present,  there  may  be  rhonchal  fremitus,  but  it 
is  frequently  absent. 

In  the  early  stage  there  is,  just  before  consolidation,  slight  dulness 
over  small  areas,  which  in  young  infants  with  thin-walled  chests  may 
have  a  slightly  tympanitic  note  (tympanitic  dulness).  Other  parts 
of  the  chest  may  have  a  vesiculotympanitic  note. 

If  bronchitis  is  present,  the  rales  of  bronchitis  may  be  heard. 
The  respiratory  murmur  is  rude.  By  careful  examination  of  all 
parts  of  the  chest  one  or  more  areas  in  which  are  heard  fine  crepitant 
rales  may  be  found.  They  may  easily  be  overlooked,  and  may  dis- 
appear when  the  infant  cries  or  coughs,  and  during  the  examination. 

Vocal  resonance  is  sliahtlv  increased  over  areas  in  which  there 
is  slight  dulness  or  beginning  consolidation.  The  whole  posterior 
aspect  of  the  thorax  from  above  downward,  and  also  the  axillary 
region  should  be  examined.  The  apex  of  the  lung  in  front,  and  the 
lower  part  of  the  thorax  in  front  and  behind  on  both  sides,  should 
be  carefully  examined,  as  well  as  the  areas  of  the  borders  of  the  lungs 
where  they  come  in  contact  with  the  chest-wall.  Increased  vocal 
resonance  and  slight  dulness  alone,  especially  over  the  apex  of  the 
right  lung  in  front  and  behind,  should  be  accepted  with  great  caution 
as  indicative  of  the  beginning  of  bronchopneumonia. 

Dyspnoea  should  not  be  looked  uj)on  as  a  sign  of  pneumonia.  The 
crepitant  rale  in  a  circumscribed  area  or  in  several  areas  is  the  sign 
pathognomonic  of  this  stage. 

Second  Stage. — Inspection  shows  no  condition  differing  from 
those  of  the  first  stage. 

If  the  area  of  consolidation  is  limited,  there  is  no  change,  because 
the  area  and  the  chest  are  small.  If  there  is  effusion  in  the  lower 
portion  of  the  pleural  cavity,  the  fremitus  may  be  diminished  over 
the  lower  part  of  the  chest,  although  the  pneumonia  is  in  the  upper 
part.  Fremitus  is  therefore  misleading,  and  is  only  confirmatory  in 
the  presence  of  other  signs. 

Percussion  reveals  dulness  in  complete  consolidation  or  dulness 
with  a  tympanitic  note  in  the  beginning  of  consolidation,  and  also 
flatness  if  fluid  is  present  over  the  consolidated  area  in  the  lower 
part  of  the  chest.  The  dulness  may  involve  a  very  small  area  or  an 
entire  lobe  of  the  lung.  There  may  be  slight  resistance  to  the  per- 
cussing flnger  over  the  consolidated  area.  The  unaffected  lung  is 
hyperresonant. 

Auscultation  gives  bronchophony  and  bronchial  or  bronchovesic- 
ular  breathing  over  the  consolidated  areas.  These  are  not  necessarily 
present  over  consolidated  lung.     In  infants  and  children  there  may 


644  DISEASES    OF    THE    EESPIBATOEY    SYSTEM. 

onlj  be  abnormally  rude  respiratory  murmur  and  increased  vocal 
resonance.  Fine  crepitant  pleuritic  rales  may  be  beard  over  tbe  con- 
solidated area. 

Diagnostic  stress  is  to  be  laid  on  complete  dulness  witb  bron- 
cbopbony  and  broncbial  breatbing. 

Third  Stage. — Palpation  will  give  increased  fremitus  if  tbe  con- 
solidated area  is  large  and  tbere  is  no  fluid  over  tbis  area. 

As  in  tbe  first  stage,  tbere  is  dulness  to  a  varying  extent,  witb  a 
tympanitic  note  sbowing  tbe  return  of  air  into  tbe  lung. 

Auscultation  gives  a  crepitant  rale,  as  in  lobar  pneumonia.  Tbe 
voice  and  breatbing  are  less  broncbopbonic.  Dulness  may  persist  for 
days  or  weeks.  In  some  cases  tbere  is  fluid,  wbicb  increases  tbe  dul- 
ness or  flatness.  Dulness,  crepitant  rales,  broncbopbony  and  bron- 
cbial breatbing  are  constant  features,  and  are  diagnostic.  In  infants 
and  cbildren,  broncbopbony  is  more  constantly  present  tban  broncbial 
breatbing.  In  tbe  broncbopneumonia  of  tbe  newly  born  infant  it  is 
sometimes  possible  to  discover  witb  tbe  small  bell  of  a  stetboscope 
areas  in  wbicb  air  does  not  enter  (atelectatic). 

Equivocal  Signs  Likely  to  te  Mistaken  for  the  Beginning  of  Broncho- 
pneumonia.— In  infants  and  cbildren,  tbe  pbysician  is  apt  to  be  easily 
misled  into  a  diagnosis  of  incipient  broncbopneumonia.  Equivocal 
signs — i.  e.j  signs  wbicb  are  not  absolutely  diagnostic — are  apt  to  be 
met  in  certain  parts  of  tbe  cbest  and  in  tbe  presence  of  rational  symp- 
toms, sucb  as  fever  or  apparent  dyspnoea,  undue  importance  may  be 
atacbed  to  tbem.     Tbese  signs  are  as  follows : 

a.  A  sligbtly  bigb  note  on  percussion  and  an  increase  of  vocal 
resonance  or  fremitus,  witb  a  rude  respiratory  murmur  on  tbe  right 
side  over  tbe  apex  in  front  or  bebind.  It  sbould  not  be  forgotten  tbat 
tbis  region,  especially  in  infants,  normally  sbows  varying  degrees  of 
tbese  signs  as  compared  witb  tbe  left  side. 

h.  A  sligbt  dnlness  over  tbe  lower  part  of  tbe  cbest  on  tbe  rigbt 
side  bebind,  due  to  tbe  presence  of  tbe  liver,  is  normal.  To  be 
abnormal,  tbe  dulness  must  be  very  marked  and  tbe  vocal  resonance 
mucb  increased.  Tbe  resistance  to  percussion  must  be  pronounced 
in  tbe  absence  of  more  positive  signs,  to  justify  a  suspicion  of  tbe 
beginning  of  consolidation. 

c.  Broncbial  or  broncbovesicnlar  breatbing  too  near  tbe  vertebral 
column  bebind  on  eitber  side,  between  tbe  scapula?,  sbould  be  cau- 
tiously interpreted.  In  some  infants,  the  breatbing  in  tbis  region  is 
normally  broncbovesicnlar.  It  is  in  tbis  region  tbat  the  diagnosis  of 
central  pneumonia  is  so  often  made — a  diagnosis  rarely  verified  by 
the  subsequent  course  of  a  case. 

d.  In  some  infants  and  cbildren,  especially  from  six  to  ten  years 
of  age,  it  is  found  tbat  ibc  fi'cmitns  and  vocal  resonance  diminish 


DISEASES    OF    THE    LUNGS.  645 

behind  from  a  short  distance  below  the  angle  of  the  scapula  to  the 
base  of  the  lung;  the  breathing  also  is  heard  less  distinctly.  A  diag- 
nosis of  pneumonia  or  consolidation  with  fluid  requires  positive  and 
unmistakable  evidence  very  low  down  behind.  The  thick  muscles  of 
the  back  and  organs  behind  the  thorax,  such  as  the  kidney  and  liver, 
obscure  slight  signs  below  the  ninth  or  tenth  rib. 

Diagnosis. — Bronchopneumonia  should  be  differentiated  from  the 
lobar  fibrinous  form  of  the  disease.  In  children  above  five  years  of 
age  this  is  not  difiicult ;  in  those  under  the  second  year,  in  whom 
fibrinous  or  lobar  pneumonia  is  not  uncommon,  a  positive  diagnosis 
of  lobar  pneumonia  cannot  be  made  until  the  stage  of  consolidation, 
and  even  at  that  time  only  as  to  distribution.  In  the  main,  it  is 
made  from  the  course  of  the  temperature.  In  lobar  pneumonia  the 
temperature  will  fall  by  crisis  after  the  usual  j)eriod.  A  marked 
leucocytosis,  which  increases  toward  the  day  of  crisis  and  then  rapidly 
diminishes,  is  also  a  characteristic  feature.  There  should  be  also  the 
physical  signs  of  lobar  consolidation. 

If  these  symptoms  and  signs  are  all  present,  it  may  be  assumed 
clinically  that  a  lobar  pneumonia  is  present.  Such  a  diagnosis  is 
always  open  to  doubt,  for  a  bronchopneumonia  may  have  the  lobar 
consolidation  and  the  leucocytosis,  but  will  rarely  have  the  critical 
drop  of  temperature  which  occurs  in  lobar  pneumonia.  As  to  the 
onset,  bronchopneumonia  may  set  in  with  a  chill,  and  lobar  without 
one.  The  complications  in  both  forms  are  identical ;  empyema  is  as 
likely  to  occur  in  one  as  in  the  other.  Lobar  pneumonia  is  rarely 
prolonged  in  duration  if  complications  are  absent,  while  the  broncho- 
pneumonic  type  of  disease  is,  as  a  rule,  of  longer  duration  and  may 
be  prolonged  into  a  chronic  course. 

Disseminated  patches  of  consolidation  in  a  lung  in  which  there 
is.  general  bronchitis  point  to  bronchopneumonia;  diffuse  bronchitis, 
with  fine  crepitations  in  the  lower  lobes  of  both  lungs,  to  broncho- 
pneumonia. The  presence  of  a  primary  disease — measles,  scarlet 
fever,  typhoid  fever,  and  influenza — will  also  influence  the  process  in 
the  lung.     The  secondary  pneumonia  is  a  bronchopneumonic  process. 

Prognosis. — The  mortality  of  bronchopneumonia,  even  under  the 
favorable  conditions  of  private  practice,  is  as  high  as  25  per  cent. 
In  hospital  practice  it  is  much  higher,  and  may  reach  50  per  cent, 
or  more.  It  is  greater  in  bottle-fed,  rachitic,  prematurely  born,  and 
syphilitic  infants,  and  is  greatest  in  the  first  year  of  life.  The  dis- 
ease is  especially  fatal  in  newly-born  infants,  and  in  cases  of  gastro- 
intestinal disorder.  The  mortality  rate  increases  in  iSTew  York  City 
in  the  months  of  December,  January,  and  February,  during  which 
the  weather  is  alternately  moist,  warm,  and  cold.  Certain  years  show 
an  increased  mortality  because  of  the  severe  nature  of  the  epidemic. 


646  DISEASES    OF    THE    JSESPIEATOEY    SYSTEM. 

At  the  bedside,  a  prognosis  is  based  on  the  condition  of  the  lung, 
temperature,  heart,  and  the  presence  or  absence  of  nervous  symptoms. 
A  persistently  high  temperature,  if  there  are  areas  of  consolidation 
in  both  lungs,  is  of  serious  import.  An  abnormal  pallor  or  slight 
cyanosis  in  a  bottle-fed  baby,  even  if  well-nourished,  is  a  danger 
signal.  Forced  and  irregular  action  of  the  diaphragm  is  serious ; 
marked  drawing  inward  of  the  sides  of  the  chest,  sometimes  as  high 
as  the  eighth  rob,  is  a  very  unfavorable  sign  in  infants.  These  cases 
show  a  depression  of  the  suprasternal  notch  as  marked  as  that  which 
occurs  in  laryngeal  obstruction.  Repeated  convulsions  and  jaundice, 
with  enlargement  of  the  spleen,  in  rachitic  infants  indicate  intense 
toxaemia.  These  cases  are  fatal.  Marked  tympanites  at  the  end  of 
the  first  week,  in  connection  with  diarrhoea  and  weakness  of  the  heart, 
is  an  unfavorable  symptom.  Dyspnoea  with  respirations  irregular  in 
rhythm  and  dej)th  denotes  diffuse  involvement  of  both  lungs,  and  is 
present  in  the  unfavorable  cases.  Cerebral  symptoms  supervening 
late  in  the  disease  are  unfavorable. 

The  favorable  signs  are  a  good  muscular  quality  of  the  first  sound 
of  the  heart,  red  lips  and  warm  surface ;  good  reaction  after  hydro- 
therapy, and  periods  of  quiet  sleep  with  full  noiseless  breathing, 
movements  of  the  bowels  normal  or  slightly  green,  and  an  absence 
of  marked  tympanites.  Caution  should  be  exercised  in  making  any 
prognosis  in  a  bronchopneumonia  which  shows  a  marked  tendency  to 
involve  new  areas  of  lung  with  repeated  chills  and  cyanosis. 

Treatment. — In  the  treatment  of  bronchopneumonia  of  infants  and 
children,  it  should  be  borne  in  mind  that  the  disease  is  a  self-limited, 
acute,  infectious  one,  and  that  there  is  no  remedy  which  can  abort  it 
or  prevent  complications.  As  in  lobar  pncimionia,  the  ill  effects  of 
the  disease  must  be  counteracted  as  much  as  possible  and  the  strength 
of  the  patient  supported.  Since  the  patients  are  of  very  tender  age, 
remedies  which  are  powerful  in  their  ultimate  effects  are  to  be  care- 
fully avoided.  The  indications  in  the  treatment  are  to  counteract 
the  effects  of  the  temperature  and  to  support  the  heart. 

Hydrotherapy. — The  temperature  in  the  most  fatal  forms  of  this 
disease  in  newborn  infants  is  below  the  normal  at  times,  and  rarely 
reaches  a  very  high  point.  In  other  cases  of  bronchopneumonia  in 
older  infants  and  children,  it  remains  persistently  above  103°  F. 
(39.7°  C).  In  these  cases,  as  in  lobar  pneumonia,  the  various  forms 
of  hydrotherapy  are  utilized.  Of  all  the  methods,  the  cold  compress 
applied  to  the  chest,  as  before  described,  seems  to  be  the  most  effica- 
cious. Compresses  lower  than  Y0°  F.  (21.1°  C.)  are  not  applied. 
The  applications  may  be  renewed  every  hour,  if  the  patient  bears 
them  well.  A  couijjit'ss  wrniig  out  in  water  at  T0°  F.  (21.1°  C.) 
will   depress  sftiiic  ]);iticnts,  causing  cyanosis  without  reaction.      In 


DISEASES    OF    THE    LUNGS.  647 

such  cases,  as  in  the  lobar  eases,  I  have  found  the  warm  bath,  105°— 
107°  (40.3°-41.6°  C),  of  the  greatest  utility  in  relieving  the  nervous 
symptoms,  such  as  restlessness  and  convulsive  tv^itchings.  Infants, 
as  a  rule,  will  not  bear  baths  below  80°  F.  (26.6°  C).  I  therefore 
do  not  utilize  the  cold  full  bath  in  infants.  I  do  not  think  it  advis- 
able to  use  the  bath  at  90°  F.  (32.2°  C.)  or  higher,  with  cold  douch- 
ing of  the  head  and  shoulders,  to  obtain  reaction  in  infants.  The 
23rocedure  rouses  the  patients  only  momentarily,  and  the  subsequent 
depression  is  greater.  Cold  packs  over  the  whole  body  are  also  heroic 
remedies,  but  are  advocated  by  some  authors. 

Medicinal. — The  heart  is  supported  b}^  means  of  digitalis,  strych- 
nine, camphor,  musk,  caffeine,  and  ammonium  carbonate.  Of  these 
agents,  the  most  useful  are  digitalis,  strychnine,  and  musk. 

Digitalis  is  administered  in  the  form  of  the  tincture.  A  drop  is 
given  for  every  six  months  of  the  age  of  the  patient.  It  should  not  be 
used  unless  the  pulse  rate  is  high,  and  should  then  be  given  every  three 
hours.  It  is  discontinued  after  being  administered  for  two  or  three 
days.  The  effects  of  stronger  preparations,  such  as  the  fluid  extract, 
cannot  be  gauged  so  carefully  as  those  of  the  tincture,  and  they  are 
therefore  less  useful.  The  cases  in  which  digitalis  is  of  the  greatest 
value  are  those  in  which  there  is  cyanosis  to  a  mild  degree,  or  exces- 
sive pallor  denoting  great  cardiac  weakness. 

Strophanthus  may  be  administered  alone  or  in  combination  with 
digitalis.     The  tincture  is  the  form  generally  used. 

Strychnine  is  one  of  the  most  useful  drugs  in  the  treatment.  An 
infant  six  months  old  will  bear  grain  V250  or  %oo  (0.0003  or  0.00025) 
very  well.  Older  infants  and  children  bear  grain  M^o  (0.0004)  quite 
well.  Strychnine  should  not  be  used  in  cases  where  there  is  increased 
excitability  of  the  nervous  system. 

Atropine,  which  is  so  useful  in  adults,  is  not  well  borne  by  infants 
and  children. 

Ammonium  carbonate  is  one  of  the  most  useful  drugs  when  for 
any  reason  digitalis  cannot  be  used.  Convulsions  or  restlessness  are 
treated  with  the  bromides  of  potassium  and  sodium,  which  may  be 
combined.  Chloral  hydrate  is  combined  with  both,  especially  where 
one  dose  of  bromide  of  potassium  and  chloral  hydrate  is  given  per 
rectum. 

I  do  not  use  poultices.  Some  authors  use  them  as  a  routine 
measure. 

Inhalations  of  benzoin  and  turpentine  are  of  doubtful  efficacy. 
They  do  not  affect  the  local  lesion  in  the  lung,  nor  do  they  act  on  the 
mucous  membrane  as  they  do  in  catarrhal  processes  of  the  nose  and 
throat.  In  some  cases  I  have  seen  harm  result  from  overloading  the 
atmosphere  with  the  odor  of  balsam. 


648  DISEASES    OF    THE    SESPIEATOSY    SYSTEM. 

The  patient  should  be  isoh^ted  from  the  healthy  children  of  the 
family  and  the  room  kept  at  a  temperature  of  from  68"  to  70°  F. 
(20°  to  21,1°  C.)  and  well  ventilated.  An  open  wood  fire  is  the  most 
satisfactory  method  of  heating  and  ventilating  the  sick-room. 

In  threatened  oedema  of  the  lungs  I  have  found,  as  in  lobar  pneu- 
monia, that  the  right  ventricle  is  best  relieved  by  nitroglycerin,  grain 
^00  to  /loo  (0.0003  to  0.006)  at  a  dose,  and  by  the  constant  adminis- 
tration of  oxygen  containing  20  per  cent,  of  nitrous  oxide. 

Alcohol  is  so  universally  used  that  the  mode  of  administering 
it  should  receive  special  mention.  Alcohol  should  not  be  used  as  a 
routine  remedy.  In  some  'of  the  milder  cases  its  use  is  superfluous. 
There  are  other  cases  in  which  its  use  must  be  suspended  because  of 
the  constant  vomiting.  In  the  severer  types  of  bronchopneumonia, 
in  which  the  temperature  is  persistently  high,  the  effects  of  the  tox- 
semia  may  be  counteracted  by  administering  whiskey.  Infants  receive 
from  minims  xx  to  xxx  (1.2  to  2.0)  ;  older  children  a  drachm  (4.0^) 
every  three  hours.  The  whiskey  should  be  well  diluted,  and  should 
be  given  after  the  nursings. 

The  feeding  of  infants  who  take  a  substitute  for  the  breast  should 
be  carefully  watched,  especially  in  bronchopneumonia,  a  disease  in 
which  diarrhoea  is  apt  to  supervene.  If  diarrhoea  is  present,  the  milk 
should  be  discontinued  and  a  cathartic  given.  The  infant  is  given 
a  high  rectal  injection  of  warm  normal  saline  solution  twice  daily, 
and  is  kept  on  solutions  of  egg-albumin  and  acorn  cocoa  and  cereal 
gruels  until  the  intestinal  symptoms  subside.  Milk  is  then  again 
given.  In  these  cases  of  intestinal  disorder  it  is  of  the  utmost  im- 
portance to  see  that  the  milk  is  fresh  and  uncontaminated. 

The  cases  not  complicated  by  diarrhoea  are  given  a  warm  high 
rectal  enema  of  the  normal  saline  solution  once  daily.  In  infants, 
this  procedure  will  ward  off  tympanitic  distention  of  the  abdomen 
and  stimulate  the  heart. 

The  cough  is  sometimes  very  harassing,  and  then  only  should  be 
relieved.  The  camphorated  tincture  of  opium  or  the  wine  may  be 
given  in  moderate  doses.  Codeine  is  useful  in  older  children.  In 
the  many  hundreds  of  cases  which  I  have  treated  I  have  not  found  it 
necessary  to  use  morphine.  Strapping  the  chest  to  relieve  pain  is 
harmful  in  infants  and  children.  The  chest  in  these  subjects  is  resil- 
ient, and  any  limitation  of  its  motion  reacts  unfavorably  in  prevent- 
ing a  full  expansion  of  the  unaffected  lung. 

Persistent  Bronchopneumonia  (Chronic  Bronchopneumonia). — 
Persistent  broncho] )ncumonia  is  a  distinct  type  of  bronchopneumonia 
the  course  of  which  extends  over  weeks  or  months,  the  patient  mean- 
while becoming  much  reduced  in  flesh  and  strength.  These  cases 
occur  in  weakly  infants,  usually  in  those  who  are  bottle-fed.     A  dis- 


DISEASES    OF    THE   LUNGS. 


649 


tinct  type  of  the  disease  complicates 
chronic  enteric  catarrh.  Cases  of  this 
class  belong  in  the  category  of  Gastro- 
intestinal Sepsis  of  Fischl,  Escherich, 
and  Czerny.  Cases  of  another  set  com- 
plicate and  follow  pertussis,  measles, 
and  influenza.  Lastly,  there  is  a  true 
tuberculous  form  which  is  not  strictly 
included  in  the  above  classification. 
The  condition  is  thus  rarely  primary. 

Symptoms. — The  infant  or  child  has 
at  first  the  symptoms  of  an  ordinary 
bronchopneumonia.  The  fever,  however, 
is  of  longer  duration  than  in  cases  which 
recover.  Cases  of  gastro-enteric  affec- 
tion or  pertussis  will  continue  to  have 
a  remittently  high  temperature  which 
may  reach  105°  (40.5°  C),  but  fall  to 
101°  or  100°  (38.3°  or  37.Y°  C.)  on 
the  same  day.  It  will  remain  normal 
for  days,  and  then  rise  again,  as  indi-  « 
cated  in  the  chart  (Fig.  136).  There  ^ 
are  cough,  dyspnoea,  emaciation,  and  ^ 
gastro-intestinal  disturbances.  In  cases 
of  enteric  catarrh  the  intestinal  disease 
takes  clinically  a  secondary  place.  Some 
of  these  cases  eventually  recover  in  spite 
of  the  progressive  emaciation  and  high 
fever.  This  is  especially  the  case  in  per- 
sistent bronchopneumonia  which  com- 
plicates pertussis. 

Blood. — In  the  case  from  which  the 
chart  was  taken  there  was  a  distinct 
increase  of  the  number  of  leucocytes 
with  each  new  rise  of  temperature  and 
fresh  invasion  of  the  lung.  The  num- 
ber of  leucocytes  mounted  as  high  as 
80,000  to  the  cubic  millimetre.  A  dif- 
ferential count  showed  that  the  poly- 
nuclear  neutrophiles  ranged  at  different 
times  from  73  to  82  per  cent,  of  the 
leucocytes  and  the  small  lymj)hocytes 
(mononuclear)  from  13  to  21  per  cent. 
As  the  disease  progressed,  there  were  also  signs  of  extreme  ansemia, 
microcytes,  megalocytes,  and  poikilocytes  being  present. 


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650  DISEASES    OF    THE    BESPIEATOET    SYSTEM. 

Physical  Signs. — ()ii  examination,  there  are  found  areas  of  con- 
solifiation  of  varying  extent,  generally  made  out  posteriorly  over  tlie 
ajjex  or  toward  the  base  of  the  lung.  There  are  signs  of  general  bron- 
chitis, increase  of  fremitus,  and  dulness  marked,  slight,  or  combined 
with  a  tympanitic  note.  There  may  be  fine  crepitations  here  and 
there  over  the  chest.  If  the  areas  are  extensive,  there  may  be  bron- 
chophony or  bronchial  breathing.  The  complete  consolidation  of 
primary  bronchopneumonia  is  not  always  present.  The  lung  is  only 
partially  consolidated,  so  that  the  vocal  resonance  may  simply  be 
markedly  increased  or  the  breathing  may  be  bronchovesicular. 

Diagnosis. — Persistent  bronchopneumonia  may  be  suspected  if 
there  is  an  area  of  dulness  at  the  apex  or  in  the  midregion  lower  lobe 
posteriorly  of  one  or  both  lungs  which  does  not  resolve  after  a  lapse 
of  weeks.  The  persistence  of  fremitus  on  the  affected  side,  espe- 
cially in  the  midregion  of  the  chest  behind,  will  aid  in  excluding  the 
presence  of  fluid  if  the  area  of  consolidation  is  located  in  the  mid- 
region,  base  or  lateral  aspect  of  the  lung.  The  rest  of  the  lung  is  in 
these  cases  resonant  or  hyperresonant.  In  doubtful  cases  the  explor- 
ing-needle  should  be  introduced  into  the  chest  to  ascertain  whether 
fluid  is  jDresent. 

Treatment. — The  treatment  is  practically  an  extension  of  the  treat- 
ment of  the  primary  condition.  If  there  is  an  affection  of  the  gastro- 
enteric tract,  it  is  treated.  If  there  is  pertussis,  treatment  proceeds 
on  the  lines  usually  followed  in  that  affection.  In  some  cases  the 
administration  of  iodide  of  potassium  in  small  doses  has  seemed  to 
have  a  beneficial  effect  on  the  course  of  the  process  in  the  lung. 

DISEASES  OF  THE  PLEURA. 

Pleurisy  (Pleuritis). — Pleurisy  in  infancy  usually  occurs  as  a 
secondary  disease ;  it  is  rarely  primary. 

Dry  Pleurisy. — Dry  pleurisy  is  the  form  in  which  the  pleura  is 
inflamed  without  any  appreciable  formation  of  exudate  in  the  ]i]eural 
cavity. 

Pleurisy  with  Effusion. ^ — Pleurisy  with  effusion,  or  subacute  pleu- 
ri.?y.  as  it  is  incorrectly  called,  is  the  form  in  which  a  serous  or  sero- 
fibrinous effusion  is  found  in  the  pleural  cavity.  The  form  in  which 
the  effusion  is  of  a  seropurulent  or  markedly  purulent  character  is 
also  called  empyema. 

Empyema. — Empyema  is  therefore  a  purulent  or  su])])urative 
pleurisy.  There  are  other  forms  of  pleurisy  which  occur  with  neo- 
])]asms  of  the  lung  or  pleurae.     These  are  not  discussed  in  this  section. 

Dry  Pleurisy. — Frequency. — Dry  pleurisy,  pure  and  simple,  is,  in 
my  experience,  clinically  not  common  among  infants  and  young  chil- 


DISEASES    OF    THE    PLEURA.  651 

dreii.  As  an  independent  affection,  it  is  found  more  frequently  after 
the  fifth  year  of  life.  Clinically,  the  cause  of  this  infrequency  in 
infancy  cannot  be  easily  explained.  Young  infants  and  children 
rarely  indicate  the  pain  which  is  the  leading  symptom.  The  disease 
is  masked  by  other  symptoms  occurring  at  the  same  time.  Older 
children  locate  the  pain  and  direct  attention  to  it. 

Etiology. — This  form  may  be  primary  or  secondary.  As  a  pri- 
mary affection  it  is  found  in  rheumatic  subjects,  especially  those  who 
are  or  have  been  subjects  of  disorders  such  as  endocarditis  or  fibrinous 
adhesive  pericarditis.  In  these  cases  the  etiology  is  the  same  as  that 
of  rheumatism.  The  condition  is  secondary  to  pneumonia.  It  may 
be  found  complicating  any  of  the  infectious  diseases — influenza,  scar- 
let fever,  measles,  typhoid  fever,  or  tuberculosis.  In  such  cases  the 
bacterial  factor  in  the  etiology  is  much  the  same  as  in  the  forms  which 
will  be  considered  under  Pleurisy  and  Effusion.  Pleurisy  may  com- 
plicate nephritis  of  the  subacute  or  chronic  type.  Traumatism  will 
cause  this  form  of  pleurisy ;  exposure  to  cold  or  wet  will  predis- 
pose to  it. 

Symptoms. — The  cases  of  simple  dry  pleurisy  not  proceeding  to 
the  formation  of  effusion  in  the  pleura,  which  have  come  under  my 
notice,  gave  few  symptoms. 

Pain. — The  children  in  the  majority  of  cases  complained  of  dis- 
tinct localized  pain  on  exertion  or  on  deep  inspiration.  There  is 
also  some  local  pain  on  external  pressure.  I  have  seen  marked  pleu- 
risy of  the  dry  form  in  which  pain  was  absent.  This  is  most  likely 
to  occur  in  pleurisies  secondary  to  nephritis.  In  the  primary  type, 
the  patients  continue  to  walk  about,  but  are  pale  and  have  an  anxious 
expression  of  the  face.  There  is  sometimes  a  rise  of  a  degree  or  more 
in  temperature  and  the  respirations  are  increased  and  superficial. 
Those  forms  described  by  Henoch  as  setting  in  with  convulsions, 
high  fever,  and  vomiting,  have  not  in  my  experience  remained  dry 
fibrinous  pleurisy,  but  have  proceeded  to  the  formation  of  effusion 
in  the  chest.  The  duration  of  dry  pleurisy  is  variable,  and  in  the 
rheumatic  forms  may  extend  over  a  long  period  of  time. 

Diagnosis. — The  diagnosis  is  not  difficult,  and  is  made  from  the 
physical  signs  and  the  history.  On  examination,  a  localized  area  over 
which  there  are  a  large  number  of  dry  crepitant  rales  is  found.  The 
rales  are  heard  so  close  under  the  ear  that  they  are  distinguishable 
from  the  crepitant  rales  of  pneumonia.  In  some  cases  there  is  a 
dry  rubbing  sound — a  pleuritic  friction — over  the  area  affected.  In 
the  cases  without  complications  there  are  no  other  signs.  There  is 
little  or  no  dulness  and  no  change  in  the  voice  or  breathing-sounds. 

Prognosis. — The  prognosis  is  very  good.  Tuberculous  disease  of 
the  lung  is  not  a  causative  agent  in  these  cases  in  children  so  fre- 


652  DISEASES    OF    THE    BESFIBAIOHY    SYSTEM. 

quently  as  in  the  adult.  The  primary  dry  pleurisies,  Tvith  proper 
care,  subside  and  gradually  disappear. 

Treatment. — The  treatment  of  dry  pleurisy  is  very  simple.  If  the 
subjects  are  rheumatic,  they  are  put  on  small  doses  of  salicylate  of 
sodium.  The  bowels  are  kept  open  with  a  saline  cathartic,  preferably 
Carlsbad  salts.  The  patients  are  kept  in  bed.  It  is  not  advisable  to 
strap  the  chest  to  relieve  pain.  The  desired  relief  can  be  secured  by 
some  local  application  of  iodine  or  a  sinapism.  Codeine  is  admin- 
istered in  moderate  doses  to  relieve  the  cough  and  pain. 

Pleurisy  with  Effusion  (Subacute  Pleurisy)  and  Empyema  {Pur- 
uleni  or  Suppurative  Pleurisy). — Frequency. — This  form  of  pleurisy 
is  common  in  infancy  and  childhood.  The  largest  number  of  cases 
occur  before  the  fifth  year  (Simmonds).  The  succeeding  five  years 
show  the  next  greatest  freqtiency,  Israel  found  29  per  cent,  of  206 
cases  to  be  purulent.  ]\Iackey  estimates  the  ptirulent  cases  at  40  per 
cent,  of  the  whole  number  in  children,  as  against  5  per  cent,  in  adults. 
Combining  the  statistics  of  Simmonds  and  Hofmokl  of  Vienna,  this 
form  is  found  to  have  greater  frequency  in  the  male  sex.  According 
to  these  authors,  the  left  side  is  more  often  the  seat  of  the  disease. 
Simmonds  found  the  disease  to  be  bilateral  in  only  7  out  of  175  cases. 
Of  170  of  my  own  cases  of  empyema,  3  were  bilateral.  Of  these 
the  majority  occurred  before  the  fifth  year,  and  25  per  cent,  before 
the  age  of  two  years.     The  youngest  patient  was  two  months  of  age. 

Etiology. — Primary  pleurisy,  whether  suppurative  or  serous,  is 
rare.  The  literature  contains  cases  of  acute  effusion  in  the  pleural 
cavity,  in  which  there  was  apparently  no  exciting  cause  or  primary 
lung  affection.  The  etiology  must  in  such  cases  remain  in  doubt. 
Infection  may  take  place  through  so  many  avenues  that  it  is  difficult 
to  point  out  the  mode  of  entrance. 

Pleuritis,  serous  or  purulent,  is  generally  secondary  in  infancy 
and  childhood.  All  forms  of  lobar  or  bronchopneumonia  may  give 
rise  to  pleurisy,  most  of  the  cases  being  traceable  to  this  source.  The 
infectious  diseases — measles,  scarlet  fever,  pertussis,  typhus  and 
typhoid  fever,  diphtheria,  forms  of  tonsillitis,  retropharyngeal  and 
mediastinal  abscess,  may  precede  or  directly  cause  an  attack  of  pleu- 
risy. Chronic  intestinal  sepsis  may  cause  empyema.  In  the  latter 
case  a  pneumonia  generally  precedes  the  pleurisy  or  is  present  at  the 
same  time.  In  sepsis  of  the  newly-born  infant,  there  may  be  a  com- 
plicating empyema.  Osteomyelitis  of  the  septic  streptococcus  variety 
may  be  complicated  by  purulent  pleurisy. 

Tuberculous  disease  of  the  lung,  actinomycosis  of  the  lung,  abscess 
of  the  liver,  abscess  in  the  mediastinum  and  abscess  in  the  abdominal 
cavity  involving  the  viscera,  may  cause  pleurisy.  Appendicitis  may 
after  the  formation  of  abscess  cause  pleuritis  by  extension  of  the 


DISEASES    OF    THE    PLEUBA.  053 

jirocess  along  the  coils  of  large  intestine  to  the  diaphragm.  Finally, 
rheumatism  may  cause  pleurisy  of  a  serofibrinous  nature.  Exposure 
to  cold  and  wet  is  undoubtedly  a  predisposing  cause.  In  children,  it 
is  common  to  have  a  history  of  a  fall  or  a  blow  occurring  just  prior 
to  the  attack  of  pleurisy. 

Morbid  Anatomy. — Pleurisies  which  accompany  acute  pneumonia 
are  the  most  frequent.  In  these,  there  may  be  a  slight  injection  of 
the  pulmonary  pleura  and  a  loss  of  the  normal  lustre.  Here  and 
there  a  few  fibrinous  threads  or  adhesions  may  be  found  coursing 
over  the  surface  of  the  pleura  or  running  from  the  costal  to  the  pul- 
monary pleura  (dry  or  fibrinous  pleurisy  (pleuritis  sicca)).  In 
other  cases,  there  is  a  thickened  condition  of  both  pleural  reflections, 
caused  by  the  deposit  of  fibrin  on  the  surface.  Sometimes  the  amount 
of  fluid  is  small,  while  the  pleura  is  very  much  thickened.  The 
pleura  itself  may  be  little  altered ;  underneath  the  flbrin  the  lymph- 
spaces  and  bloodvessels  may  be  dilated.  In  some  cases  there  is  also 
a  serous  or  seropurulent  exudate  containing  leucocytes,  endothelial 
cells,  and  bacteria.  The  fluid  may  be  clear  or  bloody,  turbid  or 
opaque,  yellow  or  greenish,  and  thinor  creamy  inconsistency.  Large 
clots  of  fibrin  may  be  found  floating  in  the  exudate.  Adhesions  may 
form  pseudo-encapsulations  of  exudate,  binding  down  the  lung  and 
preventing  its  expansion.  In  children,  however,  the  tuberculous 
pleurisies  are  most  likely  to  cause  extensive  thickening  of  the  pleura. 
In  addition  to  the  deposit  of  fibrin  on  the  costal  and  pulmonary 
pleura,  there  is  a  real  inflammatory  thickening  of  the  tissue  of  the 
pleura  itself,  with  a  deposit  of  tubercle  tissue. 

Serous  or  purulent  exudate  is  encapsulated  by  adhesions,  while 
the  lung  is  bound  down  by  layers  of  inflammatory  tissue.  In  the 
tuberculous  form  the  changes  are  progressive.  In  the  acute  inflam- 
matory forms,  the  exudates  are  absorbed  and  the  fibrinous  deposit  is 
organized  into  new  connective  tissue.  In  time  the  pleura  may  be 
restored  to  the  normal.  Adhesions,  however,  form  an  important 
factor  in  acute  pleurisy  of  children.  The  pleura  may  in  some  cases 
be  permanently  thickened  by  a  new  layer  of  connective  tissue  persist- 
ing throughout  life.  There  are  forms  of  pleurisy  not  tuberculous  in 
which  this  thickened  condition  not  only  remains,  but  extends  from 
the  pulmonary  pleura  into  the  lung  along  the  interlobular  tissue  of 
the  lung  itself.  There  are  induration  and  destruction  of  lung  tissue. 
This  induration  is  seen  in  connection  with  persistent  bronchopneu- 
monia. The  amount  of  effusion  (purulent)  is  sometimes  quite  large 
in  children,  and  may  reach  1000  to  5000  cubic  centimetres  (Sim- 
monds,  Hofmokle).  In  scurvy  and  morbus  Werlhofii,  blood  may  be 
eft'used  into  the  pleural  exudate. 

Bacteriology. — Pleurisy  or  empyema  is  divided  into  several  groups 


654  DISEASES    OF    THE    BESPIBATOBY    SYSTEM. 

according  to  the  class  of  bacteria  found  in  the  exudate.  It  is  well 
established  that  the  bacteria  are  the  essential  cause  of  the  disease. 

The  first  and  largest  gToup  is  that  in  which  the  pneumococcus  of 
Frankel,  the  lanceolate  diplococcus,  is  found.  These  cases  are  called 
metapneumonic.  Thev  may  occur  during  the  progress  of  a  pneu- 
monia or  after  it  has  run  its  course.  In  some  cases  the  process  in  the 
lung  plays  clinically  a  secondary  role.  The  pneumococcus  seems  to 
occasion  very  little  disturbance  in  the  lung  and  to  spend  its  force  on 
the  pleura.  Thus  within  three  days  after  the  initial  chill  the  pleura 
is  filled  with  serous  or  seropurulent  fluid.  Netter  found  that  of  28 
pleurisies  in  infants  and  children  53  per  cent,  were  due  to  the  pneu- 
mococcus. In  212  cases  of  empyema  I  found  the  pneumococcus  by 
culture  in  75  per  cent. 

The  second  group  comprises  those  cases  in  which  the  streptococcus 
alone,  the  staphylococcus,  or  the  streptococcus  with  the  pneumococcus 
or  staphylococcus,  is  found.  Xetter  found  that  17  per  cent,  of  his 
cases  were  of  the  strejitococcus  class ;  10  per  cent,  of  my  cases  were 
due  to  this  micro-organism.  In  cases  of  the  septic  type,  such  as  com- 
plicate sepsis  of  the  newborn  or  osteomyelitis,  or  follow  scarlet  fever, 
the  StreiDtococcus  longus  is  found  in  the  exudate.  These  cases  are 
severe.  Six  per  cent,  of  my  cases  were  caused  by  the  staphylococcus. 
In  9  per  cent,  of  my  cases  of  empyema  the  streptococcus  and  pneumo- 
coccus were  both  found  in  the  exudate.  Although  the  pleurisies  in 
which  the  streptococcus  and  staphylococcus  are  found  may  follow  a 
pneumonia,  they  may  also  be  secondary  to  a  follicular  amygdalitis, 
the  exanthemata,  typhoid  fever,  influenza,  diphtheria,  sepsis,  and 
osteomyelitis. 

The  third  group  of  cases  comprises  those  in  which  either  the 
tubercle  bacillus  is  found  in  the  exudate,  or  the  exudate  is  free  from 
micro-organisms.  The  latter  condition  is  frequently  presumptive 
evidence  of  a  tuberculous  infection  (Ehrlich).  The  tubercle  bacillus 
was  found  in  1  per  cent,  of  my  cases,  while  in  3  cases  the  findings 
both  by  cover-glass  spread  and  culture  were  negative.  This  would 
at  most  give  a  frequency^of  2  per  cent,  for  the  tuberculous  variety 
of  pleurisy  or  empyema. 

The  last  group  is  that  in  which  microorganisms  other  than  those 
mentioned  are  found  in  the  pleuritic  exudate.  Such  cases  have  been 
observed  in  connection  with  typhoid  fever  in  which  the  Eberth  bacillus 
has  been  found.  Escherich  has  found  the  coli  bacillus  in  a  case  of 
empyema.  I  have  seen  one  case  of  this  kind.  The  bacilli  of  the 
saprophytic  variety  and  those  which  cause  a  putrid  empyema  are 
found  in  cases  of  this  fourth  class. 

The  folloAving  table  shows  the  relative  frequency  of  the  various 
forms  of  pleurisy  and  empyema  with  the  varieties  of  bacteria  in  the 
exudate: 


DISEASES    OF    THE    PLEUEA. 


655 


Children, 

Netter  Kopi.ik 

28  cases.  212  cases. 

Pneumococcus                                  53.6  per  cent.  75  per  cent. 

Pneumococcus  and  Streptococcus    3.6         "  9         " 

Streptococcus 17.6         "  10         " 

Staphylococcus 6         " 

Putrid 10.7         " 

Tubercule  bacillus     ......  14.3         "  2-3         " 

Fig.  137.  Fig.  138, 


Adults. 


17  per  cent. 
2.5     " 

53        " 
1.2     " 

25        " 


<i 


> 


\ 


Fig.  139. 


Fig.  140. 


Fig.  13 (.—Streptococci  from  the  pus  of  empyema  ;  pure  culture.    Photomicrograph,   x  1000. 

iiGS.  138  and  139. — Pneumococci  (Diplococcus  lanceolatus)  from  the  pus  of  empyema 
Cover-glass  preparations  showing  capsule.     Photomicrograph,     x  1000. 

Fig.  140. — Pneumococci  (Diplococcus  lanceolatus)  ;  pure  culture  from  the  pus  of  em- 
pyema.    Photomicrograph,     x  550. 


The  most  important  fact  to  be  dediieed  from  the  statistics  is  that 
while  tuberculous  pleurisy  in  children  has  a  frequency  of  2  to  3  per 


656  DISEASES    OF    THE    FiESPIEATOBY    SYSTEM. 

cent.,  adults  show  a  mucli  greater  frequency,  many  of  the  strepto- 
coccus cases  being  tuberculous  in  the  latter  subjects.  This  figure 
added  to  the  number  of  cases  in  which  tubercle  bacilli  are  found  in 
the  exudate  would  bring  the  frequency  in  the  adult  to  at  least  the  45 
per  cent,  given  by  Bowditch  as  the  relative  figure. 

Physical  Characteristics. — The  physical  characteristics  of  an  effu- 
sion in  the  chest  are  of  clinical  importance.  An  effusion  if  purulent 
has  usually  the  gross  physical  characteristics  of  ordinary  pus.  In 
some  cases  the  effusion  is  at  first  clear  and  serous,  but  is  subsequently 
seen  to  be  purulent  without  the  occurrence  of  any  extraneous  infec- 
tion. In  other  cases  the  effusion  may  be  a  cloudy  serum,  which  on 
exploratory  puncture  is  after  a  few  days  found  to  be  purulent.  In 
rare  cases  the  effusion  or  exudate  in  the  pleura  is  hemorrhagic.  An 
effusion  of  that  character  has  not  the  same  significance  in  children 
as  in  adults.  In  the  latter  such  effusions  may  be  tuberculous  or  due 
to  some  morbid  growth  of  the  pleura ;  this  is  not  necessarily  the  case 
in  children.  I  have  had  a  number  of  cases  of  hemorrhagic  effusion 
into  the  pleural  cavity.  In  none  of  them  was  there  a  tuberculous 
element.  In  all,  streptococci  were  found  in  the  effusion,  and  in  some 
the  admixture  of  blood  could  be  traced  to  a  scorbutic  tendency.  In 
one  case,  in  an  adolescent  with  localized  effusion  of  a  hemorrhagic 
nature,  there  was  an  actinomycosis  of  the  pleura  and  lung.  The 
history  of  this  case  was  not  that  of  an  effusion  of  an  acute,  but  of  a 
subacute  chronic  nature. 

Symptoms. — There  are  no  symptoms  characteristic  or  pathogno- 
monic of  effusion  in  the  pleura  or  empyema.  The  condition  is  in  most 
cases  masked  by  the  symptoms  of  the  causal,  affection.  Cases  following 
a  pneumonia  set  in  with  a  chill  or  a  rapid  rise  of  temperature,  with 
which  there  may  be  a  convulsion  followed  by  stupor  or  cerebral  symp- 
toms. After  this  onset  the  fever  continues,  ranging  from  103°  to 
10.5°  F.  (39.4°  to  40.5°  C),  the  pulse  being  140  to  180.  There  will 
be  cough,  great  dyspnoea,  and  pain  in  the  chest,  which  is  especially 
manifest  when  the  infant  or  child  coughs.  The  breathing  is  shallow. 
xVfter  a  few  days  the  acute  symptoms  subside,  the  fever  becoming 
remittent.  The  temperature  may  be  nearly  normal.  The  dyspnoea 
continues,  although  the  temperature  and  pulse  may  be  normal  during 
]")art  of  the  day. 

In  some  of  the  cases  the  effusion  becomes  apparent  on  the  eighth 
day;  in  others  a  purulent  effusion  is  found  in  the  chest  on  the  twelfth 
or  fourteenth  day  of  the  disease.  The  effusion,  which  finally  becomes 
apparent  in  the  chest,  has  been  coincident  in  its  onset  with  a  pneu- 
monia— there  has  been  a  pleuropneumonia.  The  process  in  the  lung, 
however,  takes  a  secondary  place  in  the  clinical  picture  when  the 
effusion  in  the  pleural  cavity  has  accumulated. 


DISEASES    OF    TEE    PLEUEA. 


657 


There  is  another  set  of  cases  in  which  the  course  of  the  disease 
is  insidious.  The  patient  may  at  the  onset  have  had  for  two  or  three 
days  a  febrile  movement  which  has  subsided,  leaving  the  child  not 
quite  well  and  with  a  slight  febrile  movement  toward  evening,  a  slight 
hacking  cough,  and  some  little  pain  in  the  chest  on  exertion.  Langour 
and  loss  of  strength  are  progressive.  There  may  be  exhausting  sweats 
at  night.     Examination  of  the  chest  will  reveal  an  effusion. 

The  metapneumonic  pleurisies  in  infants  and  children  have  a 
characteristic  course.  The  patient  has  a  typical  pneumonia.  The 
temperature  on  the  ninth,  tenth,  or  thirteenth  day  may  drop  to  the 
normal  or  subnormal,  the  respirations  continuing  high.  A  gradual 
rise  of  temperature  follows,  with  physical  signs  of  fluid  in  the  chest 


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Lobar  pneumonia ;  fall  of  temperature,  by  lysis  ;  gradual  rise  after  the  thirteenth 
day,  due  to  empyema  leucocytosis.  Operation  on  the  nineteenth  day.  Recovery.  Boy, 
four  years  of  age. 

(see  Fig.  127).  The  pulse  and  respirations  rise  with  the  tempera- 
ture. Toward  evening  there  may  at  times  be  chilly  sensations.  Ex- 
ploration may  discover  fully  developed  effusion  in  the  chest,  serous 
or  purulent  according  to  the  severity  of  the  pleuritic  infection.  As 
a  rule  the  younger  the  subject,  the  more  likely  is  the  effusion  to  be  of 
a  purulent  nature.  The  duration  of  the  effusion  in  the  chest  will 
also  be  a  guide  in  determining  its  nature.  An  effusion  occurring 
after  pneumonia  in  a  young  infant  and  persisting  for  a  week  after 
the  pneumonia  has  run  its  course,  is  likely  to  be  purulent. 

Diagnosis. — There  are  some  symptoms,  such  as  continued  dyspnoea, 
a  slight  or  troublesome  cough,  exhausting  sweats,  and  a  distinctly 
intermittent  range  of  temperature,  which  in  cases  of  pulmonary  dis- 
ease should  direct  attention  to  the  pleura.  JSTone  of  these  symptoms 
is,  however,  pathognomonic  of  pleurisy,  serous  or  purulent,  since  they 
may  be  found  in  other  pulmonary  conditions.  The  diagnosis  of  pleu- 
risy with  effusion  or  empyema  should  take  into  consideration  not 
only  the  rational  symptoms,  but  also  the  physical  signs. 

Physical  Signs. — The  physical  signs  of  pleurisy  with  effusion  and 
of  empyema  are  identical. 
42 


658 


DISEASES    OF    TEE    BESPIBATOET    SYSTEM. 


Fig.  142. 


Fluid  ix  the  Chest. — 1.  The  chest  partly  filled  with  fluid.  2. 
The  chest  full  of  fluid. 

1.  The  Chest  Partly  Filled  with  Fuid. — It  is  assumed  that  the 
greater  part  of  the  fluid  is  in  the  lower  portion  of  the  chest  (Fig. 
142).     In  children  and  infants  it  does  not  cause  displacement  of  the 

viscera. 

Inspection. — Inspection  may  show 
fulness  of  the  lower  part  of  the  affected 
side;  the  lower  part  of  the  chest  moves 
less  than  the  opposite  side. 

Palpation. — Vocal   fremitus  will   be 
felt  over  the  upper  portion  of  the  chest 
in  front  or  behind,  and  will  be  lost  over' 
the  lower  portion. 

Percussion. — Percussion  of  the  chest 
in  front  will  often  give  an  exaggerated 
hyperresonant  tone  over  the  upper  lobe 
of  the  lung.  Behind,  there  is  almost 
always  dulness  to  a  greater  or  less  degree 
above  over  the  scapula,  due  either  to  thick- 
ening of  the  pleura  or  to  an  exceedingly 
thin  layer  of  fluid.  This  dulness  can  be 
distinguished  from  dulness  due  to  other 
causes  by  firm  percussion  which  will  elicit 
the  pulmonary  note  of  the  underlying 
lung.  Below,  over  the  fluid,  the  dulness  changes  to  complete  flatness. 
Auscultation. — The  voice  and  breathing  may  be  heard  over  the 
whole  side  with  as  much  intensity  as  on  the  healthy  side,  or  with 
diminished  intensity  below  the  level  of  the  fluid.  Rales,  generally 
pleuritic  crepitations,  may  be  heard  above  the  level  of  the  fluid. 
Bronchial  breathing  and  voice  may  be  heard  over  the  fluid  or  at  the 
level  of  the  fluid,  but  this  sign  is  not  absolute. 

Diagnosis  to  justify  needle  exploration  must  be  based  on  absence 
of  vocal  fremitus  over  the  fluid  and  its  presence  above  the  fluid, 
dulness  behind  above  the  fluid,  which  on  firm  percussion  gives  a  faint 
puhnonary  tone  and  flatness  over  the  fluid  with  slightly  increased 
resistance  to  the  percussing  finger. 

Note. — The  method  of  examining  infants  for  fluid  is  invariably 
that  indicated  in  the  earlier  part  of  the  book.  It  is  a  mistake  to 
examine  the  infant  as  it  lies  in  the  lap  of  the  mother,  for  in  this 
position  the  fluid  will  gravitate.  When  the  infant  lies  on  the  face, 
the  fluid  will  again  gravitate  to  the  anterior  part  of  the  chest  and 
thus  not  be  made  out.  In  the  earlier  stages  of  pleurisy  the  fluid 
only  partly  fills  the  thorax.     On  account  of  the  small  size  of  the 


Pleural  cavity  partly  filled  with 
fluid. 


DISEASES    OF    THE    PLEUBA. 


659 


thorax  in  infants,  it  is  impossible  to  determine  the  change  of  level  of 
the  fluid  bj  changing  the  position  of  the  patient. 

The  resonant  note  or  Skodaic  resonance  over  the  lung  apex  in 
front  should,  in  the  presence  of  dulness  behind  and  flatness  below, 
always  arouse  suspicion  of  fluid,  for  in  these  cases  the  lung  is  com- 
pressed upward,  forward,  and  inward,  thus  causing  the  vesiculo- 
tympanitic or  amphoric  note  in  front  and  above. 

The  chest  is  partly  filled  with  fluid,  as  is  shown  in  Figs,  143  and 
144.  I  have  quite  frequently  found  this  condition  in  infants  and 
children  who  have  for  a  long  time  lain  on  the  back,  and  in  whom 
adhesions  have  kept  a  layer  of  fluid  in  the  position  shown  in  the  flgure. 
It  will  be  assumed  for  illustration  that  the  right  side  is  afl^ected : 


Fig.  143. 


Fig.  144. 


Fluid  in  a  thin  layer  posteriorly  in  the  pleura. 


Inspection. — On  inspection,  fulness  of  the  intercostal  spaces  on 
that  side  may  be  detected ;  the  movement  of  the  thorax  is  labored,  and 
the  intercostal  spaces  may  be  drawn  inward  on  inspiration. 

Palpation. — Vocal  fremitus  due  to  the  lung's  being  in  contact 
with  the  chest-wall  may  be  present  over  the  anterior  aspect  of  the 
chest.     Posteriorly,  the  fremitus  will  be  entirely  absent. 

Percussion. — Anteriorly,  the  note  may  be  vesiculotympanitic; 
posteriorly,  there  is  complete  dulness  over  the  whole  chest,  which  is 
more  marked  below.  There  is  rarely  the  flatness  obtained  as  when 
the  chest  is  full  or  half  full  of  fluid.  There  is  also  resistance  to  the 
percussing  finger. 

By  percussing  firmly  the  note  of  the  lung  beneath  will  invariably 


660 


DISEASES    OF    THE    FiESPIBATOEY    SYSTEM. 


be  elicited;  Lreatbing-souiids  and  voice-sounds  will  be  beard  as  normal 
or  distant. 

Pleuritic  Crepitations. — Pleuritic  crepitations  may  be  beard  over 
tbe  wbole  affected  side ;  tbere  is  no  displacement  of  tbe  liver  or  beart 
on  tbe  left  side. 

Diagnosis  of  fluid  before  exploratory  puncture  must  rest  on  tbe 
complete  or  partial  absence  of  fremitus  bebind,  and  complete  dulness 
or  flatness.  Tbe  quantity  of  fluid  is  small;  tbere  is  less  resistance 
to  percussion  tban  wben  it  is  large. 

2.  The  Chest  Full  of  Fluid  (Right  Side). — Inspection. — On 
inspection  tbe  objective  signs  of  intense  or  moderate  dyspnoea  are 
found:  Tbe  cbest  on  tbe  affected  side  is  immobile;  tbe  intercostal 
spaces  are  retracted  witb  eacb  inspiration ;  tbe  affected  side  bulges 
visibly. 

Fig.  145.  Fig.  146. 


I'leural  cavity  full  of  fluid.       Flatness 
anteriorly  and  posteriorly. 


Pleural  cavity  filled  with  fluid.  liung 
displaced  upward  and  forward.  Reso- 
nance anteriorly  over  the  apex,  either 
vesiculo-tympanitic  or  of  the  cracked- 
pot  quality. 


Palpation. — \'ocal  fremitus  is  lost  over  tbe  v^'bole  side  in  front 
and  behind.      In  rare  cases  some  fremitus  is  felt. 

Percussion. — Ordinary  and  fii-iii  ])crciission  give  a  flat  note  over 
tbe  wbole  chest  in  front  and  behind;  tbe  resistance  to  tbe  percussing 
finger  is  wooden.  In  front,  flatness  ma,y  be  present  over  the  apex  of 
the  lung  (Tig,  14.">).  In  some  cases  tbe  note  over  the  apex  of  the 
lung  may  be  am])boric  or  cracked-pot  as  over  a  cavity.  This  is  due 
to  Inng  compression.      In  other  cases  tbe  resonance  in  front,  over  the 


DISEASES    OF    THE    PLEUEA. 


661 


lung  of  the  affected  side  is  vesiculotympanitic,  owing  to  the  pushing 
upward  and  forward  of  the  lung  and  to  its  distention. 

Displacement  of  the  Pleural  Fold  underneath  the  Sternum. — A 
very  important  aid  in  the  diagnosis  of  fluid  in  either  side  of  the  chest 
is  the  displacement  of  the  line  of  the  reflection  of  the  pleura  in  front. 
JSTormally  the  pleurae  of  both  sides  meet  underneath  the  sternum  in 
the  median  line.  Above,  at  about  the  level  of  the  second  rib,  they 
depart  gradually  from  each  other.  If  there  is  a  large  amount  of 
fluid  in  the  right  chest,  the  pleural  fold  of  that  side  becomes  distended 

Fig.  147. 


DisplacemeDt  of  the  left  pleural  fold  in  effusion  (empyema)   into  the  left  pleural  cavity; 
flatness  to  the  right  of  the  midsternum  as  indicated. 


and  displaced  to  the  left,  and  may  be  marked  out  above  the  heart  by 
dulness  to  the  left  of  the  midsternum.  If  the  left  chest  is  full  of 
fluid,  the  left  pleural  fold  is  displaced  to  the  right  and  there  is 
distinct  dulness  or  flatness  above,  to  the  right  of  the  midsternum 
(Fig.  14Y).    _ 

Auscultation. — Auscultatory  signs  in  infants  and  children  are 
most  puzzling  when  the  chest  is  full  of  fluid,  and  little  diagnostic 
value  can  be  attached  to  them  in  some  cases.  The  chest  may  be  full 
of  fluid  while  the  breathing  and  the  voice  may  be  heard  as  on  the 


662  DISEASES    OF    THE    BESPIRATOET    SYSTEM. 

luiaffected  side,  and  pleuritic  crepitant  rales  or  crepitations  may  be 
heard  over  the  whole  chest  behind.  In  other  cases,  the  breathing  may 
be  indistinct  and  distant,  and  in  the  lower  part  of  the  chest  lost  en- 
tirely. The  voice  may  be  bronchophonic  in  certain  localities ;  it  may 
be  of  this  quality  over  the  whole  diseased  side  of  the  chest  behind, 
or  the  tubnlar  sonnd  may  be  conducted  to  the  healthy  side.  The 
voice  may  be  normal  above  and  heard  faintly  below,  toward  the  base 
of  the  lung. 

Diagnosis  before  exploratory  puncture  rests  mainly  on  (a)  com- 
plete absence  of  fremitus;  (h)  absolute  flatness  on  percussion  with 
resistance  to  percussion;  (c)  bronchial  voice  and  breathing  over  the 
whole  chest  behind;  (d)  hyperresonance  over  the  apex,  and  displace- 
ment of  viscera,  and  of  the  pleural  fold  in  front. 

Displacement  of  Visceea.- — Liver. — In  infants  and  young  chil- 
dren the  presence  of  fluid  may  be  indicated  by  displacement  of  the 
liver  downward  on  the  right  side.  I  have  been  able  to  verify  the  dis- 
placement in  cases  in  which  large  amounts  of  fluid  were  present.  In 
infants,  the  liver  is  so  large  and  the  projection  below  the  border  of 
the  ribs  so  undetermined,  that  it  is  difficult  to  estimate  the  exact 
amount  of  displacement.  The  chest  is  so  easily  dilated  that  an  ordi- 
nary amount  of  fluid  accommodates  itself  without  markedly  displac- 
ing so  heavy  an  organ  as  the  liver.  In  children  I  have  been  able  to 
make  out  a  displacement  of  the  liver  downward  before  the  evacuation 
of  large  quantities  of  fluid.  Displacement  is  of  confirmatory  value 
in  diagnosis. 

Heart. — The  heart-apex  may  be  displaced  toward  the  median  line 
by  fluid  in  the  left  pleural  cavity.  In  children,  when  the  amount  of 
fluid  is  large,  the  apex  is  displaced  and  lies  beneath  the  lower  part 
of  the  sternum.  A  small  amount  of  fluid  will  not  always  cause  dis- 
placement, but  will  find  its  way  around  the  heart. 

Remarks  upon  the  Diagnosis  of  Fluid  in  the  Chest,  with  Exceptional 
Signs. — It  is  not  always  easy,  even  for  the  expert,  to  decide  without 
puncture  as  to  the  presence  or  absence  of  fluid  in  the  chest  of  infants 
and  young  children.  The  following  signs  will  be  of  service  at  the 
bedside. 

Duration  of  Illness. — If  an  infant  or  child  has  been  ill  for  two 
weeks  or  more  with  signs  of  pneumonia  during  the  early  part  of  the 
disease,  the  physician  should  be  watchful  in  the  presence  of  the  fol- 
lowing conditions  :  If  the  temperature  does  not  fall,  but  though  remit- 
ting still  continues ;  if  the  signs  of  consolidation  of  a  small  or  large 
area  give  place  to  dulness  or  flatness  over  a  whole  side  behind,  with 
hronchopJiony  over  the  whole  side — for  if  the  condition  of  the  infant 
is  tolerably  good,  it  is  evident  that  such  bronchophony  may  not  be 
due  to  the  total  consolidation  of  the  whole  lung,  especially  if  there  is 


DISEASES    OF    THE    PLEUBA.  663 

displacement  of  viscera,  chiefly  of  the  liver  or  the  heart;  if  there 
is  drawing  inward  of  the  intercostal  spaces  during  inspiration,  with 
real  immobility  and  bulging  of  a  side  and  dnlness  or  flatness  and  loss 
of  fremitus. 

Fluid  is  very  rarely  encapsulated  in  a  small  area  behind,  about 
the  midregion  of  the  chest.  Such  areas  are  usually  areas  of  per- 
sistent bronchopneumonia.  In  most  cases,  there  is  localized  dulness, 
above  and  below  which  there  is  vesiculotympanic  resonance,  normal 
pulmonary  resonance  or  exaggerated  resonance.  There  is  distinct 
respiratory  movement  of  the  affected  side.  On  the  other  hand,  a 
collection  of  fluid  between  the  lobes  of  the  lungs  (interlobar)  may 
give  a  localized  flatness  and  all  the  auscultatory  signs,  such  as  bron- 
chial voice  and  breathing,  of  a  local  collection  of  fluid.  This  is  gen- 
erally found  in  the  midaxillary  line  or  slightly  toward  the  posterior 
axillary  line  on  either  side. 

There  are  certain  localities  in  which  the  diagnosis  of  fluid  must 
be  made  with  reserve : 

a.  In  a  case  on  which  I  operated,  fluid  was  found  posteriorly  over 
the  situation  of  the  upper  lobe  of  the  right  lung.  The  fluid  was  com- 
pletely shut  off  from  the  rest  of  the  pleural  cavity  by  a  membrane 
stretching  from  the  thoracic  wall  to  the  interlobar  fissure  of  the  lung. 
Postmortem  showed  the  case  to  be  tuberculous,  the  lung  on  the  affected 
side  being  the  seat  of  persistent  tuberculous  bronchopneumonia.  I 
have  seen  similar  cases  which  were  metapneumonic. 

b.  Fluid  over  the  upper  lobe  in  front  only  is  rare.  I  have  seen 
four  cases  in  which  the  empyema  was  localized  over  the  apex  of  the 
lung  on  either  side.  The  signs  in  these  cases  were  diagnostic.  There 
was  flatness  on  percussion,  resistance  to  the  percussing  finger  and 
complete  absence  of  respiratory  murmur. 

c.  Fluid  over  the  lower  lobe  of  the  lung,  in  front  on  the  right  or 
left  side  without  corresponding  signs  behind,  is  uncommon. 

d.  Circumscribed  collections  of  fluid  behind  over  the  middle  re- 
gion of  the  lung  or  toward  or  in  the  axillary  line  are  exceedingly 
uncommon. 

e.  In  the  chapter  on  the  physical  signs  of  pericarditis,  it  will  be 
show;n  how  a  pleurisy  or  empyema  on  the  left  side  may  be  mistaken 
for  pericarditic  effusion. 

Physical  signs  having  led  the  physician  to  suspect  fluid,  the  chest 
should  be  explored  for  two  distinct  reasons :  to  determine  absolutely 
the  presence  of  fluid,  and  to  ascertain  whether  it  is  serous  or  purulent. 

Diagnostic  Exploratory  Puncture  of  the  Chest. — Instruments. — The 
instruments  necessary  are  an  exploring  needle,  a  millimetre  in  calibre, 
and  an  aspirating  syringe.  The  needle  should  not  be  too  short,  else 
it  may  snap  off  in  the  chest.     The  needle  and  syringe  are  boiled  for 


664  DISEASES    OF    THE    BESFIBAIOET    SYSTEM. 

a  few  moments  before  being  used.  The  patient  is  held  in  the  arms 
of  the  nurse  or  mother,  so  that  the  posterior  aspect  of  the  chest  may 
be  exposed.  Older  children  may  sit  on  a  table.  The  chest  is  scrubbed 
with  soap  and  water,  washed  off  with  ether,  then  with  alcohol,  and 
finally  with  a  solution  of  sublimate  (1:2000).  The  arms  of  the 
infant  or  child  are  firmly  held  and  the  chest  steadied  in  such  a  manner 
that  should  the  patient  start  suddenly  the  needle  will  not  break  in  the 
chest  (Plate  XXIX). 

Introduction  of  the  Needle. — The  chest  is  again  percussed  and 
the  needle  introduced  into  the  intercostal  space  in  which  pei'cussion 
elicits  the  most  marked  dulness  or  flatness.     This  rule  should  be 
invariably  followed ;  the  needle  should  not  be  introduced  into  any 
particular  intercostal  space.     On  the  right  side  the  physician  should 
avoid  putting  in  the  needle  too  low  down  (liver)  ;  on  the  left  side  he 
should  avoid  introducing  it  too  deeply  for  fear  of  wounding  a  large 
vessel  at  the  root  of  the  lung.     The  needle  should  not  be  entered  too 
near  the  vertebral  column.     The  needle  having  been  introduced  one 
or  two  centimetres,  the  piston  is  drawn  and  held  thus  a  few  seconds. 
Sometimes  the  fluid  is  thick  and  does  not  flow  freely  into  the  syringe. 
The  syringe  should  not  be  introducedandthen  withdrawn  and  pointed 
up  and  down  in  various  directions  in  quest  of  fluid,  for  fear  that  the 
struggles  of  the  patient,  even  if  he  is  firmly  held,  will  cause  puncture 
of  the  lung  and  bloodvessels.     The  needle  should  be  withdrawn  as 
rapidly  as  it  was  introduced  and  the  whole  operation  completed  in 
less  than  a  minute.     The  external  wound  is  covered  with  a  small  strip 
of  sterile  gauze  held  in  place  with  rubber  plaster.     The  needle  while 
in  the  chest  should  be  held  loosely.     If  it  is  held  firmly,  any  sudden 
movement  of  the  patient  will  cause  it  to  break  off'  in  the  chest.     The 
needle  should  not  be  introduced  too  deeply  lest  it  may  enter  a  dilated 
bronchus  and  withdraw  purulent  secretion  Avhich  may  be  mistaken 
for  empyema,  or  that  it  may  wound  the  lung  and  cause  hemorrhage 
or  pneumothorax. 

Perforating  Empyema. — An  empyema  may  perforate  externally. 
In  that  case  there  will  be  an  extensive  infiltration  of  the  tissues  ex- 
ternal to  the  ribs  on  the  affected  side,  resembling  a  large  phlegmon, 
and  the  signs  of  fluid  will  persist.  If  the  perforation  occurs  on  the 
left  side,  the  movements  of  the  heart  are  likely  to  be  conducted  to  the 
external  swelling,  and  there  is  then  what  has  been  called  pulsating 
empyema.  The  empyema  may  perforate  through  the  lung,  and  the 
signs  will  then  vary  with  the  length  of  time  during  which  the  perfora- 
tion has  existed.  It  is  customary  for  writers  to  repeat  one  another 
in  recounting  the  physical  signs  of  pneumothorax  in  a  chest  in  which 
fluid  (pleurisy  or  empyema)  is  present.  In  infants  or  very  young 
children  the  following  classical  signs  of  pyopnenmothorax  observed  in 


PLATE  XXIX 


Showing  the  correct  position  of  the  child  and  operator  in 
making  an  exploratory  puncture  for  fluid  in  the  pleural 
cavity.  The  plate  is  not  intended  to  illustrate  the  point  of 
puncture,  which  is  always   at  the   discretion  of  the   operator. 


DISEASES    OF    THE    PLEVEA. 


605 


adults  are  not  commonly  found ;  amphoric  breathing,  amphoric  voice, 
metallic  tinkle  and  succussion-sounds,  Mj  cases  were  in  children 
under  two  years  of  age.  The  perforation  in  the  lung  must  have  been 
too  small  or  too  valvular  to  permit  of  the  entrance  of  much  air  into 
the  pleural  cavity.  These  cases  at  first  showed  all  the  signs  of  the 
condition  which  was  proved,  on  introducing  the  needle,  to  be  em- 
pyema. Operation  being  refused,  after  a  few  weeks  (three  months 
after  the  beginning  of  the  disease),  the  signs  changed  as  follows : 

Periodic  expectoration  of  large  quantities  of  pus  following  cough- 
ing spells. 

Fremitus  diminished  over  the  whole  right  side  and  almost  lost 
below. 

Dulness  over  the  whole  side  in  front  and  behind,  with  tympanitic 
note  on  deep  percussion  only.  Voice  normal;  breathing  normal — at 
least  not  varying  from  that  on  the  healthy  side.  In  the  intervals  of 
expectoration,  there  were  in  some  cases  bronchial  voice  and  breathing. 


Fig.  148. 

cisL^/e       12                3                4                5                6                7                8                9 

£  101°       .. , ; ]t_.k.._.»-p-,L_\- 24._L^», 

^           --1-^        V              -  ---Nr\i 

PULSE                                               o                                                SS^^^                                       ^                              2 

RESP.                            3                            nSSSS                       S                  f? 

Empyema,   left  pleura,  followed  thirteen  days  after  operation  by  bronchopneumonia   at 
the  apex  of  the  right  lung.     Male  child,  twenty  months  of  age.     Recovery. 


]Sro  succussion-sounds,  no  tinkling,  no  amphoric  signs.  The  class- 
ical signs  seen  in  adults  are  met  in  children  above  five  years  of  age. 

Course  and  Termination. — Pleurisy  with  effusion  and  empyema 
have  been  considered  together,  because,  in  infants  and  children  under 
two  years  of  age,  the  effusion  in  the  chest  may  at  first  be  serous,  but 
subsequently  change  into  purulent  exudate.  A  serous  effusion  may 
be  followed  by  a  purulent  one ;  it  may  remain  serous  and  be  absorbed 
as  such.  Thus  it  is  best,  especially  in  infants,  to  introduce  an 
exploring-needle  into  the  chest  to  determine  the  nature  of  the  fluid 
as  soon  as  its  presence  is  suspected.  In  older  children  also  this  may 
be  done  at  the  outset.  If  a  clear  fluid  is  at  first  obtained  and  the 
symptoms  do  not  retrograde  within  a  short  time,  the  needle  should 


666  DISEASES    OF   THE   BE8PIBAT0B7    SYSTEM. 

be  again  introduced  to  determine  whetlier  the  fluid  has  remained 
serous.  It  is  frequently  found  to  be  purulent  althougb  no  infection 
has  occurred  as  a  result  of  the  first  puncture.  With  ordinary  clean- 
liness, the  possibility  of  infecting  a  serous  effusion  in  the  chest  and 
thereby  causing  it  to  become  purulent  is  very  slight.  Purulent  effu- 
sion appearing  after  the  first  exploratory  puncture  has  shown  the 
effusion  to  be  serous,  may  be  due  to  two  causes :  either  to  continuance 
of  the  pleuritic  inflammation,  or  to  the  fact  that  if  the  infant  or  child 
has  lain  quietly  in  bed  the  purulent  elements  of  the  effusion  have 
gravitated  to  the  lower  portion  of  the  chest,  leaving  a  clear  serum 
above  at  the  level  of  the  puncture. 

Prognosis. — The  prognosis  of  pleurisy  with  effusion  and  of  em- 
pyema in  infants  and  children  is  good.  If  treated  in  the  proper 
manner,  it  is  not  more  serious  than  the  original  causal  affection.  In 
private  practice,  the  patient  being  under  constant  supervision  of  the 
physician,  the  outlook  is  very  good.  An  effusion  can  be  discovered 
early  and  the  patient  relieved.  In  hospital  practice  the  results  are 
still  good  if  the  cases  are  simple  and  come  under  treatment  before 
systemic  infection  has  taken  place.  In  my  service  of  120  cases  of  all 
kinds,  there  were  20  deaths,  4  of  which  occurred  from  one  to  flve  days 
after  operation.  Sepsis  had  been  present  before  operation  and  caused 
the  fatal  issue.  The  septic  cases  therefore  give  an  unfavorable  prog- 
nosis, as  do  also  those  of  a  tuberculous  nature.  In  the  latter,  as  in 
other  forms  of  tuberculosis  in  children,  the  outlook  is  better  than  in 
the  adult  and  recoveries  are  not  infrequent. 

Of  the  20  cases  of  death  after  operation  for  empyema,  broncho- 
pneumonia, either  persistent  or  recurrent,  caused  the  fatal  issue  in  11, 
general  sepsis  in  2,  marasmus  and  ulcer  of  the  duodenum  in  1,  and 
cerebral  embolism  in  2.  A  complicating  pericarditis  of  a  suppura- 
tive nature  may  cause  death.  It  is  not  always  possible  to  diagnose 
this  condition  during  life.  The  complication  most  to  be  feared  in 
empyema  is  a  bronchopneumonia  involving  either  lung.  In  many 
cases  the  bronchopneumonia  is  present  at  the  time  of  operation,  or  it 
may  come  on  a  week  or  two  afterward  during  apparent  convalescence. 

The  prognosis  of  tuberculous  empyema  is  not  so  unfavorable  in 
children  as  in  the  adult.  In  the  former,  empyema  of  a  tuberculous 
nature,  like  other  forrhs  of  tuberculosis,  may  with  skilful  management 
make  an  apparent  recovery,  though  with  marked  deformities  of  the 
chest-wall.  In  this  form  of  empyema  the  pleura  is  thickened,  bind- 
ing down  the  lung  and  thus  preventing  expansion.  Extensive  rib 
resections  thus  become  necessary  in  order  to  close  up  the  suppurating 
cavity  left  by  the  unexpanded  lung. 

Treatment.— If  tm  exploratory  puncture  a  serous  exudate  which 
only  partly  fills  the  pleural  cavity  is  found,  the  expectant  plan  is  fol- 


DISEASES    OF    THE    PLEUEA.  667 

lowed.  The  bowels  are  kept  open  with  an  enema  or  a  saline  cathartic 
is  administered  daily.  For  this  purpose  a  saline  enema,  or  in  older 
children  a  teaspoonful  of  Carlsbad  salts  in  warm  water  mixed  with 
milk  is  efficient.  Local  vesication  is  not  needed  nor  is  it  advisable. 
The  effusion  is  absorbed  if  the  patients  are  kept  quiet  and  the  diet  is 
easily  assimilable.  Citrate  of  potassium  in  grain  v  (0.3)  doses  every 
three  hours  may  be  given  to  older  children.  If  the  fluid  increases  in 
quantity,  fills  up  the  chest,  causes  dyspnoea  or  pressure  symptoms,  and 
is  serous  in  character,  the  chest  should  be  aspirated. 

The  best  form  of  aspirator  for  the  practitioner  is  the  Potain.  The 
patient  is  aspirated  in  the  sitting  posture.  The  chest-wall  having 
been  cleansed,  the  needle  is  introduced  in  the  posterior  axillary  line 
toward  the  lower  third  of  the  chest  cavity.  It  is  not  withdrav^m  until 
the  flow  has  ceased  or  the  lung  can  be  felt  against  the  needle  in  the 
pleural  cavity.  As  soon  as  this  occurs  the  needle  is  withdrawn  and 
the  puncture  opening  covered  with  a  piece  of  iodoformized  gauze.  It 
sometimes  happens  that  there  are  signs  that  the  chest  is  filled  with 
fluid  and  yet  very  little  flows  into  the  instrument.  In  such  cases  the 
needle  should  be  withdrawn  and  introduced  into  the  chest-wall  at 
another  point.  The  coughing  attack  which  occurs  during  aspiration 
will  subside  on  the  patient's  taking  the  recumbent  posture.  If  the 
chest  is  quite  full  of  fluid,  it  is  well  not  to  empty  it  entirely.  Some- 
times alarming  syncope  with  other  signs  of  cardiac  weakness,  such  as 
cyanosis,  has  supervened.  If  a  limited  quantity  of  fluid  is  removed, 
the  absorption  of  the  rest  will  follow  rapidly. 

A  daily  saline  cathartic  is  given ;  the  patient  is  kept  quiet  and 
allowed  a  nutritious  and  easily  assimilable  diet.  The  administration 
of  salicylate  of  sodium  may  hasten  absorption,  especially  in  cases  in 
which  there  is  a  rheumatic  history.  If  there  is  pain  or  a  harassing 
cough,  small  doses  of  codeine  should  be  given. 

Empyema. — ^When  the  presence  of  pus  in  the  chest  is  once  estab- 
lished, it  is  imperative  that  it  be  evacuated  with  the  least  possible 
delay.  In  infants  and  children  it  is  not  advisable  to  temporize  by 
first  performing  aspiration.  Retention  of  even  a  limited  quantity 
of  purulent  exudate  in  the  pleural  cavity  not  only  leads  to  emaciation 
and  physical  weakness  as  a  result  of  continued  fever,  but  general 
sepsis  may  also  result.  Aspiration  is  not  efficient,^  and  is  to-day  prac- 
tically abandoned  as  a  mode  of  treatment.  The  physician  may  either 
incise  the  intercostal  space  or  resect  a  rib  to  obtain  drainage. 

Simple  incision  in  the  intercostal  space  is  efficient  in  many  cases 
of  empyema  occurring  in  the  first  eighteen  months  of  life.  In  these 
frail  patients,  excision  of  the  rib  has  been  sometimes  accompanied 
by  discouraging  results. 

The  greatest  number  of  deaths  after  any  operative  procedure  for 


668 


DISEASES    OF    THE    BESPIEATOEY    SYSTEM. 


the  relief  of  empyema  occur  in  eliildren  under  the  age  of  eighteen 
months.  The  strength  of  the  patient  should  be  supported  as  much  as 
possible.  A  general  ansesthetic  is  not  necessary  for  patients  under 
this  age.  Bronchitis  and  pneumonia  very  frequently  result  from 
the  general  use  of  anaesthetics  in  young  patients.     Local  anaesthesia 

Fig.  149. 


Kmi)y<Mii;i,  site  i>(  incision   in   line  willi   the  angle  of  the  seiijiula. 


is  all  that  is  needed.  Ethyl  chloride  in  tubes  is  efficient.  The  su]-- 
face  of  the  chest  is  carefully  cleansed  with  soap  and  water,  alcohol, 
ether,  and  sublimate.  An  incision  two  inches  long  or  thereabouts 
is  made  obliqnely  in  the  tissues  over  the  intercostal  space.  The 
space  in   which   a    ih  <  die   has   been   jn-eviously  introduced   and   pus 


DISEASES    OF    THE    PLEUEA. 


669 


found  is  chosen.  The  exploring-needle  is  always  introduced  just 
Ijef ore  operation.  Frequently,  ahhough  pus  has  been  withdrawn  from 
the  chest,  at  a  second  aspiration  none  can  be  found.  The  theory  is 
that  either  there  was  a  small  localized  collection  of  pus  at  the  first 
point  of  aspiration,  or  that  the  needle  entered  a  bronchus  and  with- 
drew secretion  collected  there. 

On  the  right  side  the  incision  should  not  be  too  low,  else  a  tube 
cannot  be  retained  in  the  chest  on  account  of  the  high  position  of  the 
diaphragm.      The  seventh  or  the  eighth  space  in  the  posterior  axillary 

Fio.   150. 


Exsection  of  rib  for  empyema  on  the  right  side.      Shows  the  resulting  deformity.     Five 
weeks  after  operation.     Child,  four  years  of  age. 


]ine  is  the  best  location  if  pus  is  present  at  this  point  (Fig.  149). 
On  the  left  side,  incisions  should  not  be  made  too  far  forward,  else 
the  drainage-tube  may  impinge  against  the  pericardium. 

The  superficial  tissues  having  been  incised,  the  intercostal  muscle 
is  incised,  the  operator  keeping  as  nearly  as  possible  in  the  median 
line  of  the  intercostal  space  and  avoiding  the  lower  border  of  the 
upper  rib,  yet  not  cutting  too  close  to  the  lower  rib.  When  the 
vicinity  of  the  costal  pleura  is  reached,  a  closed  dressing-forceps  is 
introduced  into  the  pleural  cavity  and  opened  to  widen  the  puncture. 
A  small  drainage-tube  or  two  small  tubes  are  placed  in  the  jilpural 


670  DISEASES    OF    THE    EESPIBATOBY    SYSTEM. 

cavity  and  prevented  from  falling  into  the  pleural  space  by  safety- 
pins  passed  through  them  at  the  distal  ends.  The  pus  is  not  evac- 
uated at  the  time  of  operation.  The  sudden  evacuation  of  fluid  which 
has  been  retained  in  the  chest  for  a  long  time  is  apt  to  cause  untoward 
syncopal  symptoms.  Gibson  has  made  the  excellent  suggestion  that 
as  soon  as  the  pleura  is  opened  the  drainage-tube  should  be  quickly 
introduced  into  the  chest,  the  gauze  dressings  applied,  and  the  pus 
allowed  to  escape  gradually  into  the  dressings.  The  dressings  consist 
of  a  pad  of  gauze  around  the  tubes,  covered  by  a  dry  sterilized  gauze 
dressing  which  is  renewed  every  day.  The  chest  should  not  be  irri- 
gated. ISTo  instrument  should  be  introduced  into  the  chest  cavity  to 
loosen  adhesions. 

The  whole  operation  is  extremely  simple,  and  should  not  occupy 
more  than  a  few  minutes.  Children  under  five  years,  and  even  older 
children  may  be  treated  by  this  method.  In  the  older  subjects,  how- 
ever, the  chest-wall  is  not  so  resilient;  there  are  adhesions,  and  if 
they  are  numerous  and  clots  are  abundant  in  the  exudate  a  subsequent 
excision  of  the  rib  may  be  necessary.  On  the  other  hand,  the  main 
object  of  the  practitioner  in  these  cases  is  to  evacuate  the  pus,  and 
incision  will  accomplish  this  quite  as  well  as  the  other  operation.  If 
subsequently  more  drainage  is  needed,  the  patient  will  be  stronger 
and  better  able  to  stand  the  more  serious  procedure. 

Incision  is  therefore  the  practitioner's  operation  even  in  older 
children,  vdth  whom  anaesthesia  must,  however,  be  used.  Chloro- 
form is  easily  taken ;  very  little  need  be  used.  As  soon  as  the  sMn 
incision  has  been  made,  anaesthesia  should  be  suspended. 

Excision  of  the  rib  is  best  performed  in  children  above  the  age 
of  eighteen  months,  unless  there  is  a  contraindication.  Severe  pneu- 
monia, high  fever,  cardiac  weakness,  acute  pericarditis  or  endocar- 
ditis, as  complications,  are  contraindications.  In  such  cases  incision 
alone  is  performed.  The  rib  is  excised  in  the  usual  way,  taking  two- 
or  three  centimetres  of  rib  subperiosteally  and  incising  in  the  mid- 
line of  the  posterior  layer  of  periosteum  to  enter  the  pleural  cavity. 
The  finger  is  not  inserted  into  the  pleura  to  loosen  adhesions.  After 
the  pleura  is  opened,  double  drainage-tubes  are  introduced  by  Gibson's 
method,  as  in  the  operation  of  simple  incision. 

Sinus. — After  incision  or  resection  of  the  rib,  a  suppurating  sinus 
may  remain  for  months.  If  a  probe  introduced  into  a  sinus  of  this 
kind  impinges  against  callus  or  denuded  bone,  a  so-called  secondary 
operation  is  necessary  to  take  out  the  denuded  rib  or  callus.  This 
involves  a  difficult  surgical  procedure,  which  it  is  not  necessary  to 
describe  here.  A  sinus  of  this  form  will  not  close  until  the  bone  is 
removed.  Temporizing  only  subjects  the  patient  to  the  dangers  -oi 
prolonged  suppuration  (amyloid  degeneration). 


DISEASES    OF    THE    PLEURA. 


671 


Adhesions  Binding  Down  the  Lung. — There  is  another  class  of 
cases  in  which  a  large  amount  of  fibrin  has  been  thrown  out  on  the 
visceral  pulmonary  pleura.  The  lung  is  thus  cramped  by  an  envelope 
of  thickened  pleura  and  cannot  expand.  A  large  suppurating  cavity 
or  a  suppurating  sinus  is  left  between  the  pulmonary  and  costal 
pleura.  This  cavity  must  be  made  to  close.  In  such  cases  the  pa- 
tients are  allowed  to  be  up  and  about.  They  are  taught  to  blow 
colored  fluids  from  one  bottle  to  another  in  the  way  described  by 
James,  of  ISTew  York  (Fig.  151).  Two  bottles  of  equal  size,  each 
half  filled  with  the  fluid,  are  used.  In  simple  cases  this  method  is 
very  efiicient;  in  others  it  is  of  no  avail.  The  operation  of  taking 
out  two  or  more  ribs  with  the  intervening  pleura  must  then  be  per- 
formed.    In  other  cases  a  more  extensive  operation — the  so-called 


Fig.  151. 


James'  apparatus  for  expanding  the  lungs  in  empyema. 

Estlander,  in  which  large  pieces  of  several  ribs  are  excised  with  the 
intervening  costal  pleura — is  necessary.  If  the  lung  is  firmly  bound 
down  by  a  coating  of  fibrin,  the  chest-wall  must  be  opened  by  reflect- 
ing a  flap  of  several  ribs  and  the  soft  parts.  The  pleura  is  peeled 
off  the  lung  according  to  the  method  of  Delorme.  The  lung  expands, 
the  costal  flap  is  sewn  back  in  its  place,  and  the  chest  sinus  is  in  time 
closed  as  a  natural  consequence. 

The  question  of  irrigating  the  pleural  isavity  in  the  treatment  of 
empyema  after  operation  has  been  much  discussed.  As  a  rule,  if 
the  temperature  drops  after  operation  and  remains  low,  and  the  dis- 
charge is  not  fetid,  no  irrigation  is  indicated.  If,  however,  there  are 
rises  of  temperature  after  operation,  with  a  profuse  or  fetid  discharge, 
the  chest  should  be  irrigated  once  daily  with  normal  salt  solution. 

Bilateral  Empyema. — The  treatment  of  bilateral  empyema  will 
tax  the  judgment  of  the  physician.     One  side,  preferably  the  left  in 


672  DISEASES    OF    TEE    EESPIBATOBY    SYSTEM. 

order  to  relieve  the  lieart,  is  first  operated  on  by  incision  or  rib  exsec- 
tion;  the  other  side  is  aspirated,  and  again  aspirated  if  the  flnid  or 
inis  accunmlates.  After  a  week  adhesions  will  have  formed  on  the 
operated  side,  and  the  strength  of  the  patient  will  warrant  interfer- 
ence on  the  opposite  side.  When  this  is  accomplished,  the  opening 
on  the  operated  side  must  be  closed  by  some  device,  such  as  a  pad  of 
gauze  on  which  is  placed  rubber  tissue  covering,  and  the  second  side 
may  be  operated  on  by  rib  exsection  or  incision. 

I  have  followed  this  method  in  two  cases  without  serious  accident. 
The  interval  of  a  few  days  between  the  operations  is  sufficient  to  allow 
adhesions  to  form  on  the  operated  side  to  such  an  extent  that,  when 
the  second  side  is  opened,  the  lung  of  the  side  first  operated  on  does 
not  collapse.  If  the  sides  are  operated  on  simultaneously,  the  con- 
sequent partial  collapse  of  both  lungs  causes  marked  symptoms  of 
asphyxia. 

Hemorrhagic  Pleurisy. — Simple  hemorrhagic  pleurisy  is  not  un- 
common. It  is  seen  in  pleurisy  following  simple  pneumonia,  influenza, 
the  exanthemata,  and  in  infants  or  children  in  whom  there  is  a  ten- 
dency to  scorbutus.  Cases  which  appear  to  be  rheumatic  have  been 
published  (Starck).  The  hemorrhagic  form  of  pleurisy  with  effu- 
sion may  occur  in  very  young  infants  (Lewin,  eleven  months)  or  in 
young  children.  'I  have  met  a  number  of  eases  in  children  who  sub- 
sequently made  a  complete  recovery,  and  in  whom  I  could  find  no 
tuberculous  tendencies.  The  prognosis  in  this  form  of  pleurisy  is 
therefore  much  better  in  children  than  in  adults.  In  the  latter  a 
hemorrhagic  pleurisy  is  frequently  indicative  of  a  tuberculous  factor 
in  the  etiology. 

Hemorrhagic  Empyema. — Hemorrhagic  empyema  is  also  not  un- 
common in  infants  and  children.  During  the  past  year  I  have  met 
four  cases  in  which  there  was  a  hemorrhagic  exudate.  In  one  case 
the  child  was  pale,  though  not  emaciated.  There  may  have  been  a 
scorbutic  element.  In  another  case,  in  a  bo}",  no  such  etiology  was 
indicated.  In  a  third  case,  in  a  girl,  the  child  was  much  reduced  in 
health.  In  three  cases  the  hemorrhagic  discharge  persisted  for  days 
after  the  chest  was  opened  and  streptococci  were  found  in  the  exu- 
date. In  one  case  the  discharging  pus  was  for  weeks  tinged  with 
blood.  In  none  of  the  cases  were  tubercle  bacilli  found  in  the  pleu- 
ritic exudate.  Three  of  the  cases  made  a  very  good  recovery.  In 
these  cases  also  I  am  iiK-lincd  to  believe  that  tuberculosis  is  not  always 
ail  etiological  factor. 

Subphrenic  Abscess  or  Pyopneumothorax  Subphrenicus. — The 
positive  diagnosis  of  siil)i)hrenic  abscess  should  be  made  with  reserve, 
because  no  pathognomonic  symptom  or  physical  sign  of  the  disease  is 
known.     It  is  a  very  valuable  fact  that  in  50  per  cent,  of  the  cases 


DISEASES    OF    THE    PLEUBA.  673 

thus  far  recorded,  the  abscesses  have  contained  gas  or  air.  The  con- 
dition is  rare  (Majdl)  in  adults  and  more  so  in  infants  and  children. 
The  abscess  is  situated  beneath  the  diaphragm,  and  between  that 
organ  and  the  liver.  It  pushes  the  diaphragm  upv\^ard,  and  may  thus 
encroach  on  the  pleural  space  and  simulate  a  real  pyopneumothorax. 
An  area  in  the  lower  part  of  the  thorax,  which  may  give  tympanitic 
resonance  or  tympanitic  dulness  from  the  second,  third,  or  fourth 
rib  downward,  is  thus  caused.  This  resonance  may  even  include  the 
liver,  which  is  displaced  downward.  Over  the  region  of  tympanitic 
resonance,  especially  posteriorly,  the  normal  vesicular  breathing  is 
absent  on  expiration  and  present  over  the  area  on  deep  inspiration. 

It  is  a  peculiarity  of  the  condition  that  there  may  be  amphoric 
breathing  and  metallic  tinkle  over  the  area,  while  anteriorly,  just 
above  it,  from  the  second  to  the  fourth  rib,  there  is  a  sharp  transition 
and  normal  breathing  is  heard.  Behind,  however,  on  deep  inspira- 
tion, even  over  the  region  of  tympanitic  resonance,  normal  breathing 
may  be  heard  over  the  lower  part  of  the  chest.  Over  the  situation  of 
the  abscess  the  metallic  tinkle  and  succussion-sounds  may  also  be 
heard.  As  has  been  stated,  the  liver  may  be  displaced  downward, 
crepitations  are  heard  anteriorly  over  the  liver  (perihepatitis),  or  it 
may  be  impossible  on  account  of  intestinal  conditions  to  make  out  the 
lower  border  of  the  liver.  I  have  seen  a  subphrenic  abscess  on  the 
left  side  displace  the  left  lobe  of  the  liver  and  the  spleen  downward. 
The  heart  is  not  displaced  inward  if  the  abscess  is  on  the  left  side, 
but  if  displaced  at  all,  is  so  in  an  upward  direction.  The  lower 
thorax  region  may  show  no  abnormalities  to  inspection,  while  the 
upper  abdominal  region  may  be  normal,  painful  to  pressure,  or  slightly 
oedematous. 

Diagnosis  and  Treatment. — Exploratory  puncture  is  resorted  to  in 
all  of  these  cases.  Diagnosis  will  be  aided  if  the  fluid  obtained  con- 
tains, in  addition  to  pus,  elements  which  denote  the  origin  of  the 
abscess,  such  as  food  particles,  fseces,  histological  debris  or  pigment 
from  the  liver.  In  many  cases  the  liver  suffers  from  the  vicinity  of 
the  abscess. 

The  treatment  is  surgical. 


43 


SECTION  IX. 

DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

DISEASES  OF  THE  PERICARDIUM. 

Pericarditis. — Pericarditis  is  an  inflammation  of  the  pericardium 
due  to  infection,  which  may  take  place  through  the  blood-  or  Ivmph- 
channels  or  may  occur  through  contiguity  to  infected  areas  in  neigh- 
boring structures.  The  existence  of  primary  pericarditis  or  so-called 
idiopathic  pericarditis  apart  from  rheumatism  or  infection  is  a  matter 
of  doubt.  It  is  therefore  to  be  regarded  as  secondary  to  other  condi- 
tions or  the  result  of  direct  systemic  infection. 

Occurrence.- — Pericarditis  occurs  in  foetal  life  (Billard,  Tardieu, 
Heiter)  ;  Bednar  describes  cases  in  newly  born  infants ;  it  is  common 
in  infancy  and  childhood.  Steffen  and  Baginsky  describe  a  number 
of  cases  occurring  in  infancy.  Of  66  cases  of  pericarditis  in  chil- 
dren, Baginsky  found  20  to  occur  during  the  first  year  of  life.  The 
next  greatest  frequency  was  between  the  first  and  the  fifth  year. 

Etiology. — The  majority  of  cases  occur  as  complications  of  acute 
articular  rheumatism  (Steffen,  Friedreich,  Bauer,  Baginsky),  with 
or  without  chorea.  Tuberculosis  and  pleuropneumonia  rank  next  as 
etiological  factors.  Pericarditis  occurs  in  the  exanthemata,  scarlet 
fever,  measles,  and  typhoid  fever.  It  may  complicate  pertussis, 
diarrha?al  disorders,  otitis,  meningitis,  peritonitis,  mediastinitis,  or 
any  septic  process,  such  as  osteomyelitis.  It  is  also  in  the  newly 
born  infant  concomitant  with  septic  conditions.  Finally,  trauma- 
tism may  cause  pericarditis.  The  tuberculous  form  is  uncommon 
before  the  fifth  year  of  life  (See). 

Bacteriology. — The  pyogenic  bacteria  most  frequently  found  in 
pericardial  effusions,  and  which  play  an  etiological  role,  are  the 
pyogenic  streptococci  and  staphylococci,  the  pneumococcus  of  Frankel 
and  Weichselbaum,  the  tubercle  bacillus,  the  Friedlander  bacillus,  the 
Bacterium  coli,  and  the  Bacillus  pyocyaneus  (Ernst). 

Forms.- — There  are  the  same  forms  of  pericarditis  in  children  as 
in  the  adult  subject.  The  forms  with  effusions  have,  however,  a 
tendency  to  become  purulent,  especially  in  infants  and  younger  chil- 
dren (Baginsky).  In  these  patients,  the  fibrinous  forms  result  in 
localized  or  general  adhesions  of  the  two  layers  of  the  pericardium 
and  in  partial  or  complete  obliteration  of  the  pericardial  sac  (adher- 
ent pericardium). 

674 


DISEASES    OF    THE    PEBICABDIUM.  675 

Morbid  Anatomy. — In  the  mildest  forms,  there  is  only  a  loss  of 
lustre  to  the  serosa  in  circumscribed  or  diffuse  areas.  The  fluid  in 
the  pericardial  sac  may  be  increased  in  quantity  and  may  contain 
cellular  elements.  In  other  forms,  the  surface  of  the  pericardium  is 
coated  with  a  layer  of  fibrin  of  greater  or  less  thickness.  The  fibrin 
may  be  in  the  form  of  bands  or  of  small  villous  formations.  There 
may  be  minute  hemorrhages  on  the  surface  (Delafield).  In  more 
pronounced  processes  the  fibrin  is  in  the  form  of  hemorrhagic  tena- 
cious masses  forming  a  thick  network  of  strips  or  bands  (cor  villo- 
sum) .  The  quantity  of  fluid  in  the  sac  varies.  The  fluid  may  contain 
blood. 

In  the  first  stage  of  inflammation,  the  connective  tissue  of  the 
pericardium  is  infiltrated  with  lymphoid  cells  and  the  vessels  are 
filled  with  blood.  After  the  third  day,  new  vessels  appear  in  the 
fibrinous  exudate  on  the  surface.  Fibroblasts,  spindle-shaped,  spher- 
ical, and  branching,  form  a  network  in  this  new  tissue  (Ziegler). 
Granulation  tissue  and  finally  new  connective  tissue  replace  the  fibrin- 
ous exudate,  after  a  period  of  weeks  (productive  pericarditis).  The 
so-called  opaque  areas  of  thickened  pericardium,  the  maculae  tendinese 
seen  in  adults,  are  rare  in  children  (Steffen).  Adhesions,  either 
localized  or  general,  may  form  between  the  two  layers  of  the  pericar- 
dial sac,  causing  its  partial  or  complete  obliteration. 

Tuberculous  forms  of  pericarditis  may  occur  as  miliary  infiltra- 
tion of  the  parietal  and  visceral  layers  of  the  pericardium.  There 
may  be  serous,  serofibrinous,  purulent,  or  hemorrhagic  exudate  in  the 
sac,  or  gray  cheesy  nodules  of  tubercle  tissue  may  be  present  in  the 
epicardial  and  subpericardial  tissue  (Ziegler,  Baginsky). 

Myocarditis,  circumscribed  or  general,  may  occur  in  all  forms  of 
pericarditis.     The  adhesive  forms  are  complicated  with  myocarditis. 

Symptoms. — Pericarditis  in  children  manifests  itself  by  rational 
symptoms  and  physical  signs. 

Rational  Symptoms. — At  the  bedside,  the  symptoms  of  the  differ- 
ent forms  of  pericarditis  cannot  be  divided  into  classes.  Some  of  the 
fibrinous  or  dry  forms  run  an  insidious  course  without  giving  any 
marked  symptoms  of  the  disease.  On  the  other  hand,  large  effusions 
may  make  their  appearance  without  any  previous  rational  symptoms 
which  are  characteristic.  This  is  the  case  in  the  forms  of  pericarditis 
in  infants  and  children,  which  occur  in  septic  conditions,  in  pneu- 
monia, empyema,  and  in  the  exanthemata.  If  attention  has  been  . 
drawn  to  the  heart,  it  will  be  found  that  certain  symptoms  may  be 
traced  to  the  inflammatory  process  in  the  pericardium.  If  the  pa- 
tients have  been  suffering  from  endocarditis  of  rheumatic  origin, 
empyema,  or  one  of  the  exanthemata,  they  show  the  symptoms  of 
grave  cardiac  disease.     They  have  an  anxious  facial  expression,  with 


676  DISEASES    OF    THE    CIBCULATOEY   SYSTEM. 

marked  pallor  and  cyanosis  of  the  lips.  They  do  not,  as  a  rule,  com- 
plain of  pain.  The  respirations  are  markedly  increased,  as  is  also 
the  pulse.  Older  children  may  complain  of  pain  or  uneasiness  in 
the  epigastrium.  They  also  show  marked  dyspnoea  and  orthopnoea. 
In  infants  there  are  signs  of  pain  on  breathing.  In  some  of  the 
fibrinous  forms  there  is  fever,  but  dry  forms  of  pericarditis  may  run 
their  entire  course  without  it.  The  purulent  forms  give  a  remittent 
temperature-curve.  The  pulse  is  rapid,  varying  from  120  to  150. 
In  the  forms  with  effusion,  the  pulse  is  irregular.  If  myocarditis  is 
present,  the  pulse  is  irregular  and  persistently  high,  and  there  is  an 
accompanying  increase  in  the  number  of  respirations.  There  is  no 
case  on  record  in  which  the  diagnosis  of  mediastinopericarditis  has 
beeii  made  in  a  child  during  life  and  confirmed  at  autopsy,  nor  does 
the  so-called  pulsus  paradoxus  give  any  assistance,  since  it  is  present 
in  other  conditions  in  childhood  (Steffen), 

Physical  Signs. — In  pericarditis  there  are  the  physical  signs  of  the 
dry  plastic  forms  and  the  forms  with  effusion  into  the  sac.  The 
signs  of  the  dry  pericarditis  and  those  of  the  first  stage  of  that  with 
effusion  are  practically  identical  and  may  be  considered  together. 

Inspection. — In  dry  plastic  pericarditis  and  the  first  stage  of  peri- 
carditis with  effusion  there  may  be  no  signs  to  be  detected  by  inspec- 
tion. There  may  be  an  increased  impulse,  apparent  to  the  eye,  over 
the  whole  cardiac  area  to  the  left.  When  effusion  takes  place,  little 
or  no  pulsation  can  be  made  out  over  the  cardiac  area  when  the  patient 
is  in  the  recumbent  position.  There  may. be  distinct  bulging  of  the 
cardiac  area,  varying  with  the  amount  of  fluid  present.  No  localized 
apex  impulse  is  visible  when  the  amounts  of  fluid  are  large.  There 
may  instead  be  a  diffuse  pulsation  over  the  area  of  the  apex  and  toward 
the  sternum. 

Palpation. — In  dry  pericarditis,  and  in  the  first  stage  of  pericar- 
ditis with  effusion,  there  is  a  friction  fremitus  felt  over  the  areas 
in  which  the  friction  murmur  is  heard.  This  may  be  at  the  apex, 
at  the  base,  or  along  the  right  ventricle  close  to  the  left  border  of  the 
sternum. 

The  Apex-heat  or  Impulse  and  Its  Relations  to  the  Chest-wall  in 
Pericarditis  with  Effusion. — As  effusion  takes  place,  it  is  indicated 
by  certain  physical  signs  relative  to  the  heart  apex,  and  by  the  line  of 
dulness  to  the  left.  Investigations  have  shown  that,  when  the  patient 
is  in  the  recumbent  posture,  pericardial  efl'usion  first  collects  at  the 
base  of  the  heart  around  the  great  vessels.  It  next  collects  over  the 
anterior  surface  and  in  the  aiitcrior-infci-ior  cul-de-sac  of  the  peri- 
cardium (Voinitch). 

When  the  patient  is  recumhont  the  effusion  does  not  necessarily 
]in~h  up  tlif  npex-bcat.      On  the  contrary,  it  separates  the  heart  from 


DISEASES    OF    THE    PEEICAEDIUM.  677 

the  anterior  chest-wall.  In  moderate  effusion  the  apex-beat  may  still 
be  felt  in  the  normal  position.  As  the  effusion  increases,  the  apex- 
beat  recedes  and  becomes  less  discernible  and  more  diffuse,  and  in 
large  effusion  may  disappear.  This  is  especially  the  case  if  there  is 
dilatation  of  the  heart  or  adhesions  at  the  apex.  When  the  effusion  is 
again  absorbed,  the  apex-beat  becomes  evident  in  the  former  situation. 

When  the  patient  is  sitting^  the  pericardial  effusion  collects  be- 
neath and  behind  the  heart,  and,  if  the  heart  is  not  enlarged  or  held 
down  by  adhesions,  the  apex-beat  may  at  first  be  displaced  upiuard, 
and  will  be  felt  above  and  to  the  outside  of  its  normal  position.  These 
facts  will  explain  the  failure  in  certain  cases  of  pericarditis  to  obtain 
the  displacement  of  the  apex-beat  upward.  In  one  of  my  cases,  a 
boy  of  six  years,  suffering  from  chorea,  endocarditis,  dilated  heart, 
and  pericarditis,  the  apex-beat  was  observed  in  the  beginning  of  the 
stage  of  effusion  to  be  located  in  the  sixth  space,  slightly  outside  the 
nipple  line.  Effusion  having  occurred,  the  apex-beat  could  still  be 
observed  in  its  former  locality,  but  the  area  of  absolute  dulness  indi- 
cating effusion  extended  beyond  the  apex,  four  cubic  centimetres  to 
the  left  of  the  mammillary  line.  The  effusion  disappeared  and  the 
apex  then  corresponded  with  the  line  of  dulness  of  the  left  ventricle. 

Percussion. — In  dry  fibrinous  pericarditis,  and  in  the  dry  stage 
of  pericarditis  with  effusion,  there  is  no  increase  in  the  area  of  cardiac 
dulness  directly  traceable  to  the  disease.  If  there  is  a  slight  dilata- 
tion or  relaxation  of  the  ventricle  due  to  myocarditic  complication,  the 
normal  prsecordial  dulness  may  be  more  distinct. 

The  effusion  must  have  a  bulk  of  40-60  grammes  (1^  to  2  fiuid- 
ounces)  before  definite  signs  of  its  presence  can  be  obtained. 

In  young  children,  the  area  of  dulness  due  to  pericardial  effusion 
does  not  have  the  triangular  shape  seen  in  adults.  The  position  of  the 
heart  is  more  horizontal  and  its  shape  is  retained  by  the  distended  sac. 
Thus,  to  the  left,  the  dulness  may  extend  in  a  curved  line  outside  the 
situation  of  the  nipple.  Superiorly,  it  may  extend  as  high  as  the  first 
rib.  It  then  extends  in  an  almost  horizontal  line  two  or  more  centi- 
metres to  the  right  of  the  sternum  (Fig.  152),  The  line  of  dulness  to 
the  right  of  the  sternum  then  extends  downward  in  an  almost  vertical 
line  to  the  liver  at  the  sixth  space  or  Eotch's  space  (Steffen,  Baginsky, 
Ausset).  These  facts  are  very  important  in  differentiating  dulness 
resulting  from  pericardial  effusion  from  dulness  due  to  other  causes. 
Even  in  moderate  effusion  there  is  resistance  to  the  percussing  finger. 
If  the  patient's  position  is  changed  from  the  recumbent  to  the  sitting 
posture,  the  heart  falls  forward,  the  pericardial  sac  is  distended,  and 
the  dulness  to  the  left  may  come  more  toward  the  mammillary  line 
and,  to  the  right,  toward  the  sternum  (Baginsky).  Percussion  is 
painful  in  pericardial  disease  and  the  examiner  should  bear  this  in 
mind. 


678 


VISEASES    OF    THE    CIECULATORY   SYSTEM. 


Auscultation. — The  friction  sound  is  diagnostic  in  dry  plastic 
pericarditis  and  in  the  first  stage  of  pericarditis  with  effusion.  It 
may,  at  the  outset,  be  heard  at  the  apex  (Steffen),  but  is  also  heard 
to  the  left  of  the  sternum  over  the  base,  or  below,  to  the  left  of  the 
sternum,  over  the  fourth  or  fifth  space.  Steffen  finds  it  in  children, 
at  first,  most  frequently  at  the  apex.  The  friction  may  be  heard  on 
systole  or  diastole,  or  on  systole  only.  It  may  or  may  not  accom- 
p)any  the  valvular  sounds.     It  is  of  very  limited  distribution,  is  not 


Fig.  152. 


Pericardial  area  of  dulness  due  to  effusion  in  boy,  six  years  of  age.  Chorea,  endo- 
carditis, and  pericarditis ;  x,  apex-beat  before  effusion  \  o  o  o  o,  friction  murmur ;  outer 
curved  line  shows  general  shape  of  distended  pericardial  sac. 

conducted,  and  is  of  a  fine  crepitant  quality  or  has  a  shifting,  rubbing, 
rasping  or  clicking  sound. 

In  the  case  of  a  boy  suffering  from  recurrent  chorea  and  pericar- 
ditis, there  was  a  loud  scraping  friction  at  the  apex  with  murmurs  of 
mitral  and  aortic  regurgitation,  I  was  able  in  this  case  to  confirm 
the  statement  of  Walsh,  that  a  loud  pericardial  friction  may  rarely 
be  heard  behind,  between  the  scapulae,  to  the  left  of  the  spine.  The 
friction  may  for  the  first  day  or  two  be  of  a  crepitant  quality  and 
then  acquire  a  rubbing  quality.  I  observed  this  change  in  a  child 
four  years  of  age.  The  patient  suffered  from  dilatation  of  the  left 
ventricle  with  mitral  insufficiency  and  stenosis  with  pericarditis. 
The  friction  for  two  days  was  crepitant  in  quality  and  just  audible 


DISEASES    OF    THE    PEBICABDIUM.  679 

over  the  fourth  and  fifth  spaces,  to  the  left  of  the  left  border  of  the 
sternum  and  then  acquired  a  loud  rubbing  quality.  The  murmur  is 
sometimes  very  evanescent  or  may  disappear  or  reappear  at  short 
intervals.  The  sounds  may  be  intensified  by  causing  the  patient  to 
lean  forward.  When  effusion  appears,  the  friction  sounds  may  en- 
tirely disappear,  or  may  be  heard  only  in  areas  around  the  great 
vessels  or  indistinctly  over  the  prsecordium.  A  knov^ledge  of  these 
facts  is  important  in  making  a  diagnosis  of  fluid  in  the  pericardial 
sac.     The  friction  sounds  may  reappear  on  absorption  of  fluid. 

Pleuropericardial  friction  sounds  are  rough  or  fine  sounds  ob- 
tained in  children  as  in  adults  with  the  respiratory  movements  of  the 
lung.  They  are  intensified  on  expiration  and  disappear  when  respi- 
ration is  momentarily  suspended.  They  may  be  heard  over  any  part 
of  the  prsecordium.  They  are  caused  by  the  rubbing  of  the  inflamed 
pleura  and  pericardium  against  each  other.  This  friction  is  limited 
to  one  edge  of  the  cardiac  area,  generally  the  left,  and  is  sometimes 
heard  in  the  back,  on  the  left  side. 

Diagnosis. — The  diagnosis  of  pericarditis  can  only  be  made  from 
the  physical  signs.  In  dry  plastic  pericarditis  and  the  first  stages  of 
pericarditis  with  effusion,  the  friction  sound  is  the  diagnostic  sign. 
If  a  pericardial  friction  is  once  obtained,  careful  watch  should  be 
kept  for  the  appearance  of  fluid.  It  is  not  possible  at  the  outset  to 
differentiate  a  dry  pericarditis  which  will  remain  as  such,  from  the 
first  stage  of  a  pericarditis  with  effusion. 

In  the  stage  of  effusion,  small  amounts  of  fluid  will  sometimes 
escape  diagnosis.  This  is  likely  to  occur  if  a  process  such  as  empyema 
is  in  progress  on  the  left  side.  The  first  stage  of  a  pericarditis  may 
escape  diagnosis  if  the  friction  sound  is  evanescent.  If  the  effusion 
appears  in  considerable  quantity  over  the  great  vessels,  percussion  is 
made  in  this  region,  especially  to  the  right  side  of  the  sternum  at  the 
level  of  the  second  or  third  space,  for  an  increase  in  dulness  due  to  a 
distended  pericardium.  Absence  of  dulness  in  this  region  across  the 
sternum  and  for  a  few  centimetres  to  the  right  of  the  right  border  is 
presumptive  evidence  against  the  presence  of  any  considerable  effu- 
sion. If  dulness  exists  to  the  right  of  the  sternum,  low  down  only 
on  a  level  of  the  fourth  interspace,  there  is  probably  no  pericardial 
effusion,  but,  instead,  dilatation  of  the  right  ventricle. 

Differential  Localization  hy  Percussion  of  Pleural  and  Pericar- 
dial Effusions. — In  cases  in  which  pericardial  effusion  is  very  large 
or  in  which  there  is  pleural  effusion  into  the  left  side  of  the  chest,  a 
question  may  arise  as  to  whether  there  is  a  simple  pleural  effusion, 
general  or  localized,  pericardial  effusion,  or  both.  Percussion  along 
the  sternum  will  in  simple  left  pleural  effusion  easily  mark  out  the 
displaced  left  pleural  fold.     If  there  are  large  amounts  of  fluid,  the 


680  DISEASES    OF    TEE    CIECULATOEY    SYSTEM. 

fold  of  the  left  pleura  will  be  found  to  be  distinctly  displaced  toward 
the  right  border  of  the  sternum.  The  pleural  line  will  not  pass 
beyond  the  border  of  the  sternum  to  the  right.  If  large  pericardial 
effusion  is  present,  the  dull  note  of  the  effusion  extends  beyond  the 
right  border  of  the  sternum,  especially  at  Rotch's  space.  In  left 
pleuritic  effusion  the  apex  of  the  heart  is  found  by  auscultation  to 
be  distinctly  displaced  to  a  situation  beneath  the  sternum,  while  in 
pericarditis  it  will  at  first  be  found  to  be  in  the  normal  position  and 
subsequently  to  disaj^pear  or  to  be  displaced  upward  and  outward. 

Prognosis. — The  prognosis  of  rheumatic  pericarditis  is  good.  The 
purulent  forms  of  pericarditis  are  in  the  great  majority  of  cases  fatal, 
especially  in  very  young  infants.  In  older  children,  I  have  seen  cases 
of  purulent  pericarditis,  due  to  infection  from  a  concurrent  pneu- 
monia or  empyema,  recover  with  timely  pericardotomy.  The  septic 
forms  of  purulent  pericarditis,  complicating  sepsis  of  the  newly  born 
and  forms  of  osteomyelitis,  are  fatal. 

Treatment. — The  treatment  of  the  dry  fibrinous  forms  of  pericar- 
ditis is  limited  to  the  relief  of  the  pain  and  the  treatment  of  the 
primary  condition,  rheumatism.  The  pain  is  best  relieved  by  the 
administration  of  mild  opiates.  Codeine  in  small  doses  is  efficient  in 
many  cases.  I  am  not  in  favor  of  blistering  the  prsecordial  region  in 
children,  or  of  applying  a  seton,  as  is  done  in  adults.  If  the  heart  is 
tumultuous,  small  doses  of  digitalis  in  the  tincture  form  and  the  con- 
stant application  of  an  ice-bag  over  the  prascordial  region  are  the  most 
effective  remedies.  Some  authors  believe  that  the  ice-bag  is  also  a 
very  powerful  means  of  limiting  the  inflammation.  In  rheumatic 
or  choreic  cases  the  salicylate  of  sodium  is  given,  or  if  this  disagrees 
with  the  patient,  the  ordinary  bicarbonate  of  sodium  in  doses  of 
grains  x  (6.5)  three  or  four  times  daily.  Perfect  rest  in  bed,  long 
after  the  process  has  run  its  course,  is  indicated,  on  account  of  the  ill 
effects  of  strain  on  the  heart  affected  by  myocarditic  changes  which 
are  undoubtedly  present  in  many  of  the  cases. 

When  effusion  has  taken  place,  the  question  of  the  advisability 
of  puncturing  and  exploring  the  pericardium  always  arises.  It  is 
very  difficult  to  choose  the  proper  time  for  entering  the  pericardium. 
I  have  had  a  number  of  cases  of  pericarditis  with  effusion  recover 
without  being  subjected  to  what  is  at  best  a  hazardous  procedure.  I 
temporize  until  the  orthopnoea  and  cyanosis  are  extreme  and  evidences 
of  pressure  are  marked.  Too  nmch  ini])ortance  should  not  be  attached 
to  ordinary  symptoms.  On  the  other  hand,  if  the  temperature  is  high 
and  daily  remits  to  near  the  normal,  there  may  be  a  purulent  effusion. 
If  after  a  reasonable  length  of  time  tbe  patient  steadily  loses  ground 
and  the  signs  of  eff'usion  are  marked,  the  pericardium  should  be 
entered  to  determine  the  character  of  the  exudate.     If  it  is  serous, 


DISEASES    OF    THE    PEBICABDIUM.  681 

ordinary  aspiration  will  suffice,  but  if  purulent,  the  operation  of  peri- 
cardotomy  should  be  performed.  Pericardial  puncture  or  incision  is 
performed  in  the  same  manner  as  in  adults. 

It  may  be  remarked  that  Henoch  has  never  punctured  the  peri- 
cardium. In  one  of  his  cases,  postmortem  examination  showed  small 
sacculated  purulent  collections  of  fluid  which  could  hardly  have  been 
evacuated  by  a  single  puncture.  I  found  a  similar  condition  post- 
mortem in  a  case  in  which  puncture  of  the  pericardium  was  under- 
taken, and  resulted  in  puncture  of  the  heart. 

Morse,  on  the  other  hand,  advocates  early  puncture  of  the 
pericardium. 

Adherent  Pericardium, — Adherent  pericardium  is  an  agglutina- 
tion, localized  or  complete,  of  the  visceral  and  parietal  walls  of  the 
pericardial  sac  which  becomes  partly  or  completely  obliterated. 

Etiology.- — The  condition  follows  either  a  dry  plastic  pericarditis 
or  a  pericarditis  with  effusion,  in  the  stage  of  absorption.  In  the 
latter  case,  if  the  absorption  of  fluid  has  been  observed  and  the  redux 
friction-sound  obtained,  adhesion  of  the  pericardium  may  be  sus- 
pected from  certain  signs;  otherwise,  diagnosis  even  within  probable 
limits  would  in  many  cases  be  an  impossibility.  Infants  and  chil- 
dren who  have  withstood  an  attack  of  pericarditis,  especially  of  the 
rheumatic  form,  are  very  prone  to  contract  this  form  of  pericarditis. 
In  most  cases  it  causes  myocarditis  of  a  progressive  type ;  hence  the 
importance  of  understanding  the  condition.  Hypertrophy  of  the 
heart,  atrophy  of  the  heart,  or  dilatation  of  that  organ  may  accom- 
pany adherence  of  the  pericardium. 

Sjmiptoms. — The  symptoms,  especially  in  'the  rheumatic  cases, 
develop  late  in  the  disease  when  myocarditis  supervenes.  The  con- 
dition may  prove  fatal  by  progressive  affection  of  the  cardiac  muscle. 
One  of  my  cases,  of  rheumatic  origin,  showed  postmortem  no  valvular 
lesion.  There  were  complete  obliteration  of  the  sac  and  extreme  dila- 
tation. The  symptoms  are  at  first  negative.  There  may  be  a  fric- 
tion sound  or  a  roughening  of  the  cardiac  sounds  at  the  base.  There 
is  in  some  cases  a  drawing  inward  of  the  apex  area  of  the  chest  at  the 
xiphoid  cartilage.  A  wave-like  undulation  of  the  cardiac  area  with 
an  increase  of  cardiac  dulness  is  sometimes  found.  There  may  be 
persistent  asystole  not  controlled  by  digitalis  (See).  In  my  cases 
there  were  angina,  a  persistently  high  pulse  with  an  increase  in  the 
number  of  respirations,  and  in  the  last  stages,  all  the  symptoms  of 
non-compensatory  dilatation  of  the  ventricle  which  are  seen  in  val- 
vular disease.  There  may  be  a  mitral  systolic  murmur  simulating 
that  seen  in  valvular  disease.  In  spite  of  all  these  symptoms,  it  is 
rarely  possible  to  make  a  positive  diagnosis  during  life. 


682  DISEASES    OF    THE    CIECULATOEY   SYSTEM. 

DISEASES  OF  THE  HEART. 

The  height  of  the  heart  and  of  the  great  vessels  in  children  does 
not  differ  after  the  third  year  from  that  of  the  adult.  The  ratio  of 
the  transverse  to  the  sagittal  diameter  of  the  chest  in  nev^born  infants 
is  2  to  1,  while  in  adults  it  is  3  to  1.  This  fact  should  not  be  forgotten 
in  estimating  the  size  of  the  heart  in  infants  and  children.  What  in 
an  adult  might  appear  to  be  a  large  heart,  v^ould  be  normal  to  the 
infant  or  young  child. 

Position. — In  the  first  year  of  life  the  long  axis  of  the  heart  is 
more  horizontal  than  in  later  childhood  or  in  adult  life  (Rauchfuss). 
At  the  third  year,  the  position  of  the  heart  is  practically  that  found 
in  the  adult  (D wight). 

As  the  child  becomes  older  the  heart  assumes  more  nearly  the 
vertical  position,  and  in  older  children  the  apex-beat  may  be  found 
0.75  to  1  centimetre  within  the  mammillary  line.  The  situation  of 
the  mammillary  line  is  variable  in  young  children ;  the  nipple  is  over 
the  fourth  rib,  but  further  removed  from  the  midsternal  line  than  in 
older  children  on  account  of  the  great  transverse  as  compared  to  the 
longitudinal  diameter  of  the  thorax.  In  older  children  the  heart 
areas  closely  resemble  those  in  the  adult.  In  infants  and  young  chil- 
dren there  are  certain  variations  from  the  adult  condition  which 
should  be  borne  in  mind. 

Size. — The  heart  is  relatively  larger  in  the  infant  than  in  the 
adult,  having  0.89  per  cent,  of  the  body  weight  in  the  newborn  infant, 
while  in  the  adult  it  has  only  0.52  per  cent.  (Vierordt). 

Apex-beat. — The  apex-beat  in  the  newborn  infant  may  be  felt 
higher  than  in  the  adult.  On  account  of  the  greater  breadth  of  heart 
as  compared  with  that  of  the  chest  the  apex  is  external  to  the  mammil- 
lary line.  Steffen  says  that  normally  the  apex-beat  may  be  found  1 
centimetre  external  to  the  mammillary  line,  or  in  the  mammillary 
line,  or  internal  to  the  mammillary  line.  The  apex-beat  in  infants 
and  children  is  in  the  fifth  space. 

Inspection. — Inspection  shows  in  some  cases  an  undulatory  move- 
ment over  the  whole  cardiac  region.  This  is  normal  as  long  as  it  is 
confined  to  the  left  of  the  sternum,  but  an  undula.tory  movement  to 
the  right  of  the  sternum  is  probably  indicative  of  dilatation  of  the 
right  ventricle  with  or  without  hypertrophy.  In  rachitis  the  cardiac 
region  is  sometimes  unduly  prominent.  This  condition  must  be  dis- 
tinguished from  the  more  pronounced  fulness  in  the  prsecordium 
occurring  in  cases  of  hypertrophy  or  of  pericardial  effusion. 

Children  who  in  early  childhood  have  suffered  from  cardiac  dis- 
ease with  dilatation  and  hypertrophy  of  the  left  ventricle  may  show 
a  marked  prominence  of  the  prsecordium. 


DISEASES  OF  THE  HEART.  683 

The  apex-beat  should  not  be  mistaken  for  an  apparent  apex-beat 
which  is  sometimes  seen  in  yonng  children  in  whom  the  intercostal 
space  to  the  left  of  the  large  cardiac  dulness  is  raised  with  each  pulsa- 
tion of  the  apex.  Percussion  in  these  cases  will  show  the  apex  to  be 
situated  elsewhere  to  the  left  and  downward.  In  some  cases  the  apex, 
instead  of  pushing  the  intercostal  space  forward,  draws  it  distinctly 
inward.  This  is  in  part  due  to  adhesions  between  the  heart,  peri- 
cardium, and  parts  external  to  the  pericardium.  When  children  are 
struggling,  the  systolic  impulse  of  the  heart  is  seen  to  be  communi- 
cated to  both  the  carotid  artery  and  the  jugular  vein,  the  vein  getting 
its  impulse  from  its  proximity  to  the  artery.  The  vein  may  be  found 
to  be  collapsed  and  the  artery  to  show  an  impulse  on  systole. 

Palpation. — The  following  points  may  be  determined  by  palpation 
with  the  tips  of  the  fingers  or  full  palm : 

1.  Location  of  the  apex-beat. 

2.  Sometimes  the  location  of  the  left  boundary  of  the  heart. 

3.  The  force  of  the  systole,  hypertrophy  or  dilatation  of  the  heart, 
especially  if  pulsation  is  evident  to  the  right  of  the  sternum, 

4.  Transposition  of  the  heart  to  the  right. 

5.  The  closure  of  the  valves  of  the  pulmonary  artery  in  the  second 
or  third  space  near  the  sternum. 

6.  Murmurs  which  cause  friction  (pericardial)  or  thrills  (endo- 
cardial). 

7.  Rhythm  of  the  heart  action. 

Auscultation. — In  infancy  the  muscular  quality  of  the  first  sound 
is  not  apparent.  The  heart-sounds  have  more  the  character  of  the 
tick-tack  of  a  watch.  The  muscular  character  of  the  first  sound  fully 
develops  toward  the  second  year  of  life.  All  through  infancy  and 
childhood  there  is  a  natural  accentuation  of  the  second  pulmonic 
sound.  Too  much  importance  should  not  be  attached  to  the  accentua- 
tion even  if  it  is  marked. 

Percussion. — The  percussion  of  the  heart  has  been  the  subject  of 
much  refinement  of  methods,  which  only  tends  to  confuse  a  simple 
matter.  The  following  method  will  be  found  suitable  for  most  clin- 
ical purposes : 

The  line  of  demarcation  is  the  midsternal  line.  All  reckonings 
as  to  the  limits  of  cardiac  dulness  may  be  safely  made  from  the  mid- 
sternal  line,  the  situation  of  the  mammillary  line  being  variable  in 
children.  The  right  border  of  the  sternum  is  not  a  good  line  to 
reckon  from,  since  the  width  of  the  sternum  varies.  The  recumbent 
posture  is  preferable  in  infants ;  both  the  recumbent  and  upright  posi- 
tions are  suitable  in  older  children. 

Method  of  Locating  the  Line  of  Dulness  of  the  Left  Ventricle. — To 
locate  the  external  boundary  of  the  ventricle,  we  begin  to  percuss  in 


684 


DISEASES    OF    THE    CIECULATOBT   SYSTEM. 


the  lines  parallel  with  the  second,  third,  fourth,  and  fifth  ribs  toward 
the  heart,  from  the  axillary  line  or  the  anterior  axillary  line.  To 
percuss  from  the  midsternal  line  outward  does  not  in  children  give 
as  good  results. 

To  locate  the  external  border  of  the  right  ventricle^,  we  percuss 
along  the  fourth  rib  or  fourth  space  toward  the  sternum  from  the  right 
mammillary  line.  In  young  infants  a  portion  of  the  right  auricle 
and  ventricle  will  be  found  as  high  as  the  junction  of  the  second  rib 
and  the  sternum  (Symington),  but  it  is  an  ultra-refinement  of  per- 


FiG.  153. 


Form  of  the  normal  relative  cardiac  dulness  in  a  child  two  and  one-half  years  of  age. 

cussion  to  try  to  make  out  the  projection  of  this  part  of  the  right 
auricle  to  the  right  of  the  sternum.  It  is  found,  anatomically,  that 
the  curve  of  the  auricle  to  the  right  of  the  sternum  begins  at  the  third 
space,  and  is  most  marked  behind  the  fourth  costal  cartilage.  It  is 
sufficient  for  clinical  purposes  to  make  out  this  most  projecting  part 
of  the  heart  to  the  right  of  and  behind  the  sternum. 

The  apex  of  the  heart  is  generally  made  out  by  percussing  along 
the  fifth  rib  or  fifth  space  from  the  antero-lateral  axillary  line  toward 
the  midsternal  line.      The  external  boundary  of  the  left  ventricle  is 


DISEASES  OF  THE  HEART.  685 

in  children  slightly  outside  the  apex-beat.  The  area  of  cardiac  diil- 
ness  which  is  absolute  and  which  is  uncovered  by  lung  can  best  be 
made  out  by  percussing  from  above  downward  over  the  cardiac  area. 
In  children  or  infants  this  area  cannot  be  marked  out  as  definitely  as 
in  the  adult.  The  younger  the  child  or  infant,  the  greater  the  diffi- 
culty. In  infants  and  children  interest  centres  rather  in  the  apparent 
size  of  the  heart  (relative  dulness)  than  in  the  area  uncovered  by  lung. 
The  dulness  extends  to  the  right  and  left  of  the  midsternal  line, 
at  a  level  with  the  fourth  rib,  as  is  indicated  by  the  following  figures 
compiled  from  Steffen's  tables : 

Infants  under  one  year right  v.  4  to  6.5  cm.  to  right. 

left  V.  3.5  to  6.25  cm.  to  left. 
Children  one  to  two  years right  v.  4  to  6.5  cm.  to  right. 

left  V.  4  to  7.25  cm.  to  left._ 
Children  two  to  three  years right  v.  4.5  to  7.5  cm.  to  right. 

left  V.  4.5  to  6.5  cm.  to  left. 
Children  five  to  six  years right  v.  5.5  to  7.25  cm.  to  right. 

left  V.  5  to  8.25  cm.  to  left. 
Children  nine  to  ten  yeai-s right  v.  5.5  to  8.5  cm.  to  right. 

left  V.  5.5  to  8.5  cm.  to  left. 

Enough  has  been  selected  to  show  that  the  actual  size  of  the  heart 
as  obtained  by  percussion  in  infants  and  children  is  extremely  vari- 
able, and  the  examiner  must  be  guided  by  the  relative  size. 

Congenital  Heart  Disease. — Congenital  heart  disease  may  be  sus- 
pected from  certain  physical  signs  which  occur  in  that  condition  and 
are  in  a  sense  characteristic  of  it.  These  are  cyanosis,  changes  in  the 
area  of  cardiac  dulness,  and  the  presence  of  characteristic  murmurs. 

Cyanosis. — The  cyanosis  which  is  characteristic  of  congenital  heart 
disease  does  not  occur  in  any  of  the  acquired  cardiac  lesions.  It  is 
most  common  in  the  congenital  forms  of  pulmonary  stenosis  of  the 
artery,  conus,  or  ostium.  On  the  other  hand,  it  may  be  absent  in 
marked  congenital  disease,  as  in  deficient  ventricular  septum  and  open 
ductus  arteriosus.  In  the  latter  disease  it  may  appear  late  in  the 
condition,  only  at  intervals,  or  not  at  all.  It  may  be  absent  at  birth 
and  appear  in  infancy  or  childhood. 

Cardiac  Dilatation  and  Hypertrophy. — The  presence  of  a  murmur  of 
congenital  origin  does  not  necessarily  presuppose  change  from  the 
normal  in  the  area  of  cardiac  dulness.  In  fact,  a  normal  cardiac  area 
is  sometimes  evidence  of  the  congenital  character  of  a  murmur. 
Hypertrophy  of  the  left  ventricle  should  be  present  with  hypertrophy 
of  the  right  ventricle,  and  a  murmur  to  indicate  open  ductus  arteri- 
osus. Dilatation  of  the  right  ventricle  is  of  value  when  present  with 
a  murmur  indicating  stenosis  at  the  pulmonary  valve.  On  the  other 
hand,  marked  congenital  defects  may  exist  without  any  change  in  the 
size  of  the  ventricle.  Moreover,  if  the  cardiac  area  is  enlarged  and 
the  apex  impulse  weak,  congenital  disease  may  be  suspected.  The 
weak  apex  impulse  indicates  dilatation. 


686  DISEASES   OF    THE    CIECULATOBT   SYSTEM. 

Murmurs. — The  murmur  most  cbaracteristie  of  congenital  heart 
disease  is  a  systolic  murmur  at  the  situation  of  the  space  between  the 
second  and  third  costal  cartilage  to  the  left  of  the  sternum,  and  not 
conducted  into  the  arteries  of  the  neck.  It  is  only  when  there  are 
complicated  defects  that  murmurs  are  conducted  into  the  carotids 
(open  ductus  arteriosus). 

Foetal  endocarditis  affecting  the  tricuspid  or  mitral  valves  is  rare, 
and  therefore  murmurs  of  congenital  origin  are  rare  at  these  valves. 

Diastolic  murmurs  are,  so  far  as  congenital  lesions  are  concerned, 
of  theoretical  interest  only. 

Systolic  murmurs,  such  as  those  heard  in  defects  of  the  ventric- 
ular septum,  and  which  cannot  be  attributed  to  valvular  disease, 
occur  at  the  pulmonic  valves.  In  these  cases  the  murmur  has  no 
point  of  greatest  intensity,  but  is  heard  not  only  at  the  valve,  but 
also  over  the  whole  prsecordium.  The  valvular  sounds  are  distinct. 
The  most  marked  congenital  defect  or  disease  of  the  heart  may  exist 
without  any  murmur  or  other  physical  signs  during  life. 

In  simple  pulmonary  stenosis,  the  second  pulmonic  sound  is  weak ; 
in  cases  complicated  with  open  ductus  arteriosus  and  hypertrophy  of 
the  ventricles,  it  is  accentuated;  in  cases  of  pulmonary  stenosis  and 
deficient  ventricular  septum,  it  is  either  weak  or  very  low. 

Positive  Diagnosis  Often  Impossible. — The  diagnosis  of  the  exact 
lesion  in  congenital  heart  disease  is  in  many  cases  impossible.  The 
reason  for  this  is  easily  found  in  the  fact  that  if  the  patient  lives 
longer  than  the  first  year,  the  lesion  is  rarely  simple,  but  occurs  with 
other  congenital  defects  in  the  heart.  Another  cause  is  the  rarity  of 
autopsies  on  uncomplicated  cases  which  have  been  carefully  studied 
during  life.  Lastly,  in  complex  cases,  even  if  the  diagnosis  has  been 
confirmed  at  autopsy,  it  is  impossible  to  say  to  what  degree  the  lesion 
diagnosed  and  the  other  complicating  conditions  found  at  autopsy 
have  been  the  cause  of  the  signs  and  symptoms  found  during  life. 
The  physical  signs  of  congenital  heart  disease  vary  as  the  lesion  is  a 
simple  one  or  is  combined  with  other  congenital  defects.  The  follow- 
ing classification  of  congenital  heart  disease  of  developmental  or 
foetal  endocarditic  origin  will  be  found  useful  in  clinical  work : 

1.  Septum  Defects. — Auricular  (foramen  ovale)  ;  ventricular. 

2.  Pulmonary  Artery. — Stenosis  of  the  conus,  trunk,  or  ostium : 
(a)  simple  cases  (before  the  end  of  the  first  year  of  life)  :  (&)  com- 
plicated cases  with  open  foramen  ovale  or  ductus  arteriosus,  defect  of 
the  ventricular  septum,  or  transposition  of  the  great  vessels. 

3.  Aortic  Valve  Stenosis  or  General  Contraction  of  the  Aortic 
System. — The  first  may  be  due  to  developmental  defect  or  to  foetal 
endocarditis;  the  second,  to  developmental  defect.  All  aortic  condi- 
tions anomalous  in  character  have,  so  far  as  is  known,  not  been  diag- 
nosed during  childhood. 


DISEASES  OF  THE  H.EAET. 


687 


4.  Valvular  Anomalies. — Valvular  anomalies  of  the  semilunar 
valves,  due  to  foetal  endocarditis  or  developmental  irregularities  are 
of  purely  scientific  interest. 

5.  Open  Ductus  Arteriosus  or  Botalli. —  (a)  Simple;  (&)  com- 
bined with  septum  defects  or  pulmonary  stenosis. 

6.  Transposition  of  the  Heart  and  Congenital  Anomalies  of  the 
Pericardium  (of  purely  scientific  interest). 

Fig.  154. 


Clubbed  fingers  of  congenital  heart  disease.     Child,  six  years  of  age. 


From  the  above  account,  which  I  have  modified  for  practical  use 
from  the  classification  of  Vierordt,  it  will  be  seen  that  only  the  con- 
genital anomalies  of  the  auricular  ventricular  septum,  the  pulmonary 
artery,  and  the  ductus  arteriosus  Botalli  are  of  interest  to  the  clinician. 

Stenosis  of  the  Pulmonary  Artery,  Conus,  or  Ostium.^ — -This  is 
the  most  common  of  all  congenital  heart  lesions.  If  found  after  the 
thirteenth  month  of  life,  it  is  in  most  cases  combined  with  a  con- 
genital deficiency  of  the  septum  ventriculorum.  Rauchfuss  found 
a  simple  stenosis  in  only  10  per  cent,  of  all  the  published  cases. 
Most  of  the  cases  are  due  to  foetal  endocarditis. 


688  DISEASES    OF    THE    CIECULATOBY   SYSTEM. 

Physical  Signs. — Simple  Stenosis. — Simple  stenosis  of  the  artery, 
conns,  or  ostinm,  f onnd  only  before  the  thirteenth  month  (Rokitansky ) . 

Cyanosis. — Early  and  congenital  cyanosis  and  signs  of  venous 
stasis,  snch  as  clubbed  extremities  of  the  fingers,  even  in  young  in- 
fants. In  cases  which  are  met  in  later  life  the  clubbing  of  the  ex- 
tremities of  the  fingers  and  cyanosis  of  the  finger-tips  are  marked. 

Blood. — The  blood  shows  so-called  polycythemia.  The  number 
of  erythrocytes  is  increased  above  the  normal,  being  7  to  9,000,000  to 
the  cubic  millimetre,  as  shown  by  some  of  my  cases.  The  hemo- 
globin index  is  also  increased.  The  white  blood-cells  are  normal  in 
number.  The  increase  in  erythrocytes  is  regarded  as  an  evidence  of 
compensatory  over-production  caused  by  the  increased  need  of  oxygen 
on  part  of  the  tissues  in  the  presence  of  cyanosis. 

Murmur. — A  systolic  murmur  heard  with  greatest  intensity  at 
the  situation  of  the  pulmonary  valve  to  the  left  of  the  sternum,  be- 
tween the  second  and  third  costal  cartilages,  and  not  conducted  into 
the  carotids.  A  weakened  second  sound  at  the  pulmonary  valve; 
dilatation  of  the  right  ventricle. 

Simple  stenosis  is  found  in  infants,  but  is  rare.  In  most  cases 
there  are  also  present  congenital  defect  of  the  ventricular  septum, 
open  ductus  arteriosus,  tricuspid  changes,  or  the  aorta  arises  from 
the  right  ventricle  or  both  ventricles.  The  following  facts  should  be 
kept  in  mind  in  the  diagnosis  of  cases  occurring  after  the  thirteenth 
month  of  life: 

If  the  above  signs  are  present  with  a  weakened  second  pulmonic 
sound,  there  being  absolutely  no  conduction  of  the  murmur  into  the 
carotids,  it  may  be  assumed  that  there  is  a  pulmonary  stenosis  with 
an  open  foramen  ovale. 

Conduction  of  the  murmur  into  the  arteries  of  the  neck,  with  a 
very  distinct  though  not  accentuated  second  pulmonic  sound,  points 
to  the  presence  of  a  septum  defect  with  a  pulmonary  stenosis. 

An  accentuated  second  pulmonic  sound  with  conduction  of  a 
murmur  of  a  loud  buzzing  character  into  the  subclavian  and  carotids, 
and  a  hypertrophy  of  the  right  and  also  of  the  left  ventricle,  will  sup- 
port the  theory  of  a  pulmonary  stenosis  with  a  patency  of  the  ductus 
arteriosus  (Hochsinger).  In  these  cases  of  open  ductus  arteriosus 
there  is  a  thrill  and  a  distinctly  defined  area  of  dulness  in  the  second 
space  to  the  left  of  the  sternum  above  the  base  of  the  heart.  This 
dulness  is  of  great  diagnostic  import.  It  is  due  to  the  dilated  great 
vessels  at  the  base  of  the  heart. 

As  an  exception  to  the  above  classification  may  be  mentioned  the 
case  of  Sansom,  in  which  cyanosis  and  extreme  ansemia  were  present. 
Ill  rare  cases,  the  second  pulmonary  sound  may  be  very  low.  The 
murmur  may  be  conducted  into  the  axilla,  the  right  heart  not  being 
dilated. 


DISEASES  OF  THE  EEAET.  689 

Open  Ductus  Arteriosus  or  Ductus  Botalli  {Ductus  Disease). — 
This  is  a  very  rare  congenital  defect.  There  are  in  the  literature 
only  20  cases  of  uncomplicated  open  ductus  arteriosus  in  which 
autopsy  confirmed  the  clinical  diagnosis.  Of  these,  only  5  occurred 
in  infants  under  one  year  of  age,  and  5  others  ranged  from  the  first 
to  the  tenth  year  (Vierordt).  The  complicated  cases  occur  with 
stenosis  of  the  pulmonary  artery,  septum  defects  of  small  extent,  and 
open  foramen  ovale. 

Physical  Signs. — Cyanosis. — Cyanosis  is  not  present  in  the  major- 
ity of  cases,  or  if  present  is  so  only  at  intervals  and  is  not  marked. 

Murmur. — The  murmur  is  a  loud  buzzing  systolic  murmur  heard 
with  greatest  intensity  over  the  pulmonary  artery,  and  not  conducted 
downward,  but  conducted  to  the  left  of  the  sternum  into  the  veins  of 
the  neck  (Plochsinger). 

There  is  an  accentuated  second  pulmonic  sound  which  can  be 
heard  in  the  carotids. 

Right  Ventricle. — The  presence  of  hypertrophy  of  the  right  ven- 
tricle tends  to  confirm  the  diagnosis ;  if  the  left  ventricle  is  also  hyper- 
trophied,  greater  certainty  is  added.  This  is  of  great  moment,  since 
hypertrophy  of  the  left  ventricle  is  not  present  in  any  of  the  other 
congenital  defects,  except  those  connected  with  the  anomalies  of  the 
aorta  and  aortic  system  and  which  have  only  a  scientific  value,  since 
the  literature  contains  no  cases  which  have  been  diagnosed  during 
life.  The  dulness  in  the  second  space  referred  to  under  Pulmonic 
Stenosis  is  also  of  value. 

Congenital  Defects  of  the  Auricular  Ventricular  Septum ;  Defects 
of  Auricular  Septum;  Open  Foramen  Ovale. — Inasmuch  as  44  per 
cent,  of  the  autopsies  upon  individuals  who  during  life  showed  abso- 
lutely no  signs  of  cardiac  disturbances  reveal  a  patency  of  the  foramen 
ovale,  the  diagnosis  of  the  condition  as  an  uncomplicated  entity  should 
be  made  with  great  reserve.  This  congenital  defect  is  generally 
found  to  exist  in  connection  with  other  defects  of  a  congenital  nature 
(stenosis  of  the  pulmonary  artery). 

Cyanosis  has  been  found  in  all  the  cases  in  which  autopsy  has 
been  made.  In  a  case  recorded  by  Foster,  there  was  cyanosis  with 
a  varying  systolic  and  presystolic  murmur  at  the  sternal  end  of  the 
third  or  fourth  costal  cartilage. 

Walshe  denies  that  a  patency  of  the  foramen  ovale  may  of  itself 
cause  a  murmur.     - 

Congenital  Deficiency  of  the  Ventricular  Septum;  Maladie  de 
Roger. — Autopsies  have  shown  that  this  condition  may  exist  during 
life  without  giving  any  signs  of  its  presence.  Moreover,  it  is  so  often 
combined  with  other  congenital  heart  anomalies,  such  as  stenosis  of 
the  pulmonary  artery  or  ostium,  or  ductus  Botalli  that  the  signs  of 

44 


690  DISEASES    OF    THE    CIJRCULATOEY   SYSTEM. 

the  ventricular  condition  must  of  necessity  be  obscured  by  those  of  the 
complicating  defect. 

Cyanosis. — Cyanosis  has  been  present  in  some  cases  of  uncompli- 
cated defect  of  the  ventricular  septum  (Miiller)  and  absent  in  others. 
It  is  present  in  the  cases  complicated  v^ith  pulmonary  stenosis. 

Murmur. — According  to  Roger,  a  loud  systolic  murmur  is  heard 
over  the  whole  prsecordium,  toward  the  median  line,  over  the  upper 
third  of  the  cardiac  area.  According  to  others  (Miiller),  the  murmur 
has  no  special  point  of  greatest  intensity.  It  is  not  conducted  into 
the  vessels  of  the  neck.  I  have  seen  such  a  case  in  a  child  13  months 
of  age. 

Eauchfuss  calls  attention  to  the  fact  that  with  this  murmur  the 
distinct  valvular  character  of  the  heart-sounds  at  the  various  valves 
should  be  heard.  The  case  of  Miiller  was  that  of  a  cyanotic  infant 
two  months  old.  A  loud  murmur  having  no  special  point  of  greatest 
intensity  was  heard  over  the  whole  cardiac  area.  The  valvular 
sounds  were  distinctly  heard.  Autopsy  showed  uncomplicated  defect 
of  the  ventricular  septum. 

Acute  Endocarditis. — Acute  endocarditis  is  an  inflammation  of 
the  lining  membrane  of  the  heart.  That  covering  the  valves  and 
their  immediate  vicinity  is  the  area  generally  affected.  There  is  also 
an  inflammation,  slight  or  marked,  of  the  muscle  tissue  of  the  heart, 
and  in  some  cases  there  is  inflammation  of  the  pericardium.  Endo- 
carditis thus  involves  structures  of  the  heart  other  than  the  endo- 
cardium. Acute  endocarditis  may  be  benign,  septic  or  as  formally 
called  malignant.  Between  the  two  extremes,  there  are  all  gradations 
as  to  severity.  All  forms  of  endocarditis  are  caused  by  infection 
which  in  the  malignant  variety  is  of  the  severest  septic  type.  Foetal 
endocarditis  affects  the  right  side  of  the  heart;  after  birth,  the  left 
heart  is  chiefly  affected.  The  condition  is  less  frequent  before  than 
after  the  fifth  year  of  life,  and  occurs  with  equal  frequency  among 
boys  and  girls  (Steffen). 

Etiology. ^ — Acute  endocarditis  occurs  most  frequently  with  acute 
articular  rheumatism,  but  may  appear  in  any  infectious  disease.  It 
is  often  found  in  scarlet  fever;  less  often  in  measles.  I  have  seen 
it  in  rare  cases  of  erythema  nodosum  (2  cases).  It  may  occur  with 
typhoid  fever,  diphtheria,  influenza,  pneiimonia  (ISTetter),  cerebro- 
spinal meningitis,  and  tuberculosis.  In  fact,  all  forms  of  sepsis,  such 
as  osteomyelitis,  either  foetal  or  in  the  newborn  infant  or  in  children, 
may  be  accompanied  by  endocarditis.  Endocarditis  is  present  in  16 
per  cent,  of  the  cases  of  chorea  and  is  always  present  in  fatal  cases 
of  that  disease. 

Bacteriology. — The  most  important  bacteria  bearing  an  etiological 
relaliojiship  to  endocarditis  are  the  streptococci  of  the  various  varie- 


DISEASES  OF  TEE  HEART.  691 

ties  and  the  Staphylococcus  pyogenes.  Harbitz  divides  endocarditis 
into  the  infectious  and  the  non-infectious  varieties.  He  found  bac- 
teria in  the  vegetations  in  most  of  the  infectious  cases,  streptococci  in 
39,5  per  cent,  and  staphylococci  in  18.6  per  cent,  of  the  cases;  other 
bacteria,  such  as  the  pneumococci,  were  also  found.  The  cases  in 
w^hich  no  bacteria  were  found  were  healed  cases.  He  thinks  that  the 
staphylococci  most  often  cause  pysemic  endocarditis  with  ulcerations 
and  metastatic  abscess.  Welch  and  Lenhartz  found  streptococci  in 
ulcerative  endocarditis.  The  Diplococcus  pneumoniae  is  next  in  im- 
portance as  an  etiological  factor.  Wright  found  the  Bacillus  diph- 
theria in  one  case.  Other  bacteria,  such  as  the  Gonococcus,  the 
Bacillus  endocarditidis  griseus  (Weichselbaum),  the  Micrococcus 
endocarditidis  rugatus  and  capsulatus,  the  Diplococcus  tenuis  (Klem- 
perer),  have  been  found  in  cases  of  adult  endocarditis.  Although 
they  are  all,  as  well  as  the  Bacillus  typhosus,  doubtless  capable  of 
causing  the  same  process  in  children,  actual  clinical  cases  are  still  to 
be  published. 

All  forms  of  endocarditis  are  thus  septic  processes  due  to  the 
circulation  in  the  blood  of  bacteria  or  their  toxins.  In  some  cases 
it  is  possible  to  discover  the  point  of  entrance  of  the  bacteria  into 
the  circulation,  in  others  it  cannot  be  fixed  upon.  The  various  forms 
of  endocarditis  are  not  so  uncommon  in  infants  as  is  supposed.  The 
tonsil  is  a  great  avenue  for  the  entrance  of  bacteria  or  toxins  into 
the  circulation  (Cheadle).  It  is  believed  that  many  cases  of  endo- 
carditis in  children  originate  in  this  manner  (Packard).  I  have 
frequently  met  with  endocarditis  in  which  the  only  other  clinical 
manifestation  was  a  slight  redness  or  swelling  of  the  tonsils.  The 
integrity  of  the  endothelium  of  the  endocardium  must  be  compro- 
mised if  bacteria  have  invaded  the  tissue  of  the  valvular  endocardium 
(Prudden).  It  is  supposed  that  the  toxins  produced  by  the  bacteria 
circulating  in  the  blood  reduce  the  resistance  of  the  endothelial  lining 
of  the  endocardium,  thus  preparing  the  soil  for  bacterial  invasion. 

Morbid  Anatomy. — In  some  cases  the  only  lesion  is  a  swelling  of 
the  valves.  They  are  thickened  and  succulent,  their  surface  being 
smooth.  The  basement  substance  is  swollen  and  there  is  an  increase 
of  connective-tissue  cells  (Delafield).  In  other  cases  the  borders  of 
the  valves  present  transparent,  gelatinous,  whitish-yellow  or  reddish 
formations,  varying  from  the  size  of  a  pin's  head  to  that  of  a  bean. 
These  are  irregular  in  shape,  cover  both  surfaces  of  the  valves,  and 
may  be  single  or  multiple.  They  are  also  seen  on  the  chordae  tendinese. 
The  free  border  of  the  valve  is  warty  or  papillomatous  (endocarditis 
verrucosa  or  polyposa)  (Ziegler).  The  papillae  may  appear  on  the 
free  surface  of  the  valves.  There  may  be  a  loss  of  substance  with  the 
formation  of  adherent  thrombi  of  a  whitish  or  reddish  color  and  of 


692 


DISEASES    OF    THE    CIECULATOEY   SYSTEM. 


tenacious  consist eiicv  (endocarditis  ulcerosa).  Small  foci  of  pus 
may  be  present  in  the  heart  substance  (endocarditis  pustulosa). 

Bacterial  invasion  of  the  surface  of  the  valves  results  in  loss  of 
substance,  formation  of  thrombi,  and  changes  in  the  nuclei  of  the  con- 
nective tissue  (necrobiosis).  The  mitral  valve  being  more  vascular 
is  sooner  affected  than  the  aortic  or  pulmonary  valves.  Exudation  on 
the  valve  is  replaced  by  new  connective  tissue ;  excrescences  and  new 
formations  become  permanent.  If  the  bacteria  penetrate  deeply, 
thickening  of  the  valve  results.  Large  thrombi  are  organized,  and 
the  valves  become  shrunken  and  distorted.  Ulceration  and  loss  of 
substance  may  result  in  perforation  of  the  valves.  The  thrombi  just 
mentioned  are  sometimes  made  up  of  blood-plates ;  in  other  cases  leuco- 
cytes, blood-cells,  and  fibrin  in  varying  amounts  are  present. 

There  may  be  exudative  pericarditis.  The  myocardium  is  the 
seat  of  degeneration,  which  leads  to  dilatation,  abscess  or  aneurism 
of  the  heart  muscle.  Through  the  separation  of  portions  of  the 
thrombi  or  of  the  vegetations  on  the  valves,  these  particles  may  be 
carried  into  the  circulation.  Containing,  as  they  do,  bacteria  (my- 
cotic emboli), they  cause  secondary  infections  with  necrosis  or  abscess 
in  the  kidney,  spleen,  and  brain. 

Fig.  155. 


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Endocarditis  complicating  influenza.     Second  week   of  the  Illness.     Mitral  systolic 
murmur  developed  under  observation.     Female  child,  four  years  of  age. 


Symptoms. — The  symptoms  of  acute  endocarditis  are  those  of  some 
general  infection.  They  are  not  in  infants  and  children  so  charac- 
teristic as  to  direct  attention  to  the  heart.  Infants  cannot  and  chil- 
dren do  not  complain  of  pain,  palpitation,  or  uneasiness  in  the  pre- 
cordial region  as  adults  sometimes  do,  and  therefore  unless  the  heart 
is  carefully  examined  as  a  routine  procedure,  the  simple  cases  of 
endocarditis  will  escape  observation.  The  most  interesting  cases  are 
those  which  begin  with  all  the  symptoms  of  an  attack  of  influenza 
or  tonsillitis.  There  are  fever,  rapid  pulse,  and  an  increase  of  the 
respirations  to  36  or  40.     The  fever,  however,  does  not  subside  in 


DISEASES  OF  TEE  HEART. 


693 


the  time  occuiDied  by  the  course  of  one  of  the  above  affections;  it 
continues  high,  103''-104°-105°  F.  (39.4^-40.5°  C),  with  morning 
or  afternoon  remissions. 

In  such  cases  a  most  careful  examination  of  the  lungs  and  other 
organs  fails  to  reveal  anything  abnormal.  The  heart,  however,  shows 
the  presence  of  endocardial  inflammation.  In  some  obscure  cases, 
there  is  an  increasing  pallor  with  a  slight  daily  rise  of  half  a  degree 
or  a  degree  in  body  temperature,  which  will  continue  for  days  or  even 
weeks  and  give  rise  to  a  suspicion  of  paludal  poisoning.  There  is 
also  an  increasing  pallor.  Examination  of  the  heart  reveals  the 
lesion.  In  other  cases  there  are  a  very  slight  but  increasing  pallor, 
weakness,  and  indefinite  pains  in  the  bones  and  joints.  In  children, 
more  than  in  the  adult  subject,  we  are  apt  to  have  monarticular  affec- 
tions of  a  rheumatic  nature. 


Fig. 

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Chronic  cardiac  disease,  hypertrophy,  and  dilatation  of  the  left  and  right  ventricles. 
Enlarged  liver  and  spleen,  ascites,  cyanosis,  recurrent  attacks  of  endocarditis.  Tempera- 
ture by  rectum  shows  a  subnormal  range.     Boy,  twelve  years  of  age. 


I  have  seen  several  cases  of  monarticular  joint-affection  with  an 
endocardial  murmur  in  childhood.  One  case  was  that  of  a  child  two 
years  and  eight  months  of  age,  another  was  that  of  a  child  eight  years 
of  age.  In  the  one  case  the  ankle  was  swollen,  painful,  and  slightly 
reddened.  There  was  no  temperature.  There  had  been  slight  pain 
in  one  knee  some  days  previous  to  the  ankle-affection.  In  the  other 
case  the  metatarsal  phalangeal  joint  of  the  small  toe  was  involved. 

In  young  children  the  joints  may  be  painful,  and  still  no  history 
of  joint-pain  will  be  given,  and  the  first  indication  of  pain  is  a  decided 
limp  in  walking.  These  obscure  joint-pains  are  the  first  symptom  of 
endocarditis.  The  rheumatic  cases  are  as  a  rule  easily  diagnosed. 
The  heart  should  be  regularly  examined  in  such  cases.  The  endo- 
carditis which  complicates  chorea  sometimes  runs  its  entire  course 
without  any  rise  in  the  body  temperature.  I  have,  however,  been 
able  in  such  cases  to  confirm  the  statement  of  Jlirgensen,  that  the 
normal  diurnal  temperature  variations  are  distorted — that  is  to  say, 
the  morning  temperature  may  be  higher  than  the  evening  tempera- 


694  DISEASES    OF    TEE   CIBCULATOBY   SYSTEM. 

ture.  In  other  cases  of  chorea  there  is  a  distinct  rise  of  tempera- 
ture without  any  increase  of  the  respirations  and  pulse-rate  during 
the  active  stage  of  the  endocarditis.  x\fter  the  symptoms  of  chorea 
have  begun  to  decline  there  is  occasionally  a  rise  of  temperature  last- 
ing a  day  or  more,  which  may  indicate  a  slight  recurrence  of  the 
endocarditis.  In  other  cases  I  have  observed  a  subnormal  tempera- 
ture of  a  degTee  or  more  lasting  for  days.  This  occurred  in  a  case 
of  recurrent  endocarditis.  Thus  the  temperature  is  not  at  all  charac- 
teristic. The  heart  in  children  is  extremely  irregular.  It  may  vary 
from  60  to  120  per  minute  within  a  few  days,  and  may  vary  at  differ- 
ent times  of  the  same  day.  Under  such  conditions  it  may  be  sur- 
mised that  there  is  a  myocarditis.  The  respirations  are  increased. 
The  children  do  not  complain  of  the  heart. 

In  pneumonia,  scarlet  fever,  and  measles,  the  endocarditis  is 
masked  by  the  symptoms  of  the  primary  disease. 

Physical  Signs. — A  murmur  which  develops  while  a  child  is  under 
observation  is  indicative  of  acute  endocarditis. 

Inspection. — Inspection  may  reveal  nothing  abnormal,  or  there 
may  be  extreme  irregularity  of  the  action  of  the  heart.  There  may 
be  increased  action,  as  evinced  by  visible  pulsation  over  the  cardiac 
area. 

Palpation. — Palpation  also  may  reveal  nothing  abnormal ;  there 
may  be  a  thrill  over  the  apex. 

Percussion. — Percussion  at  first  reveals  nothing  abnormal.  In 
some  cases  there  is  a  slight  dilatation  of  the  left  ventricle  (Steffen) 
as  the  disease  progresses.  I  have  seen  this  dilatation  in  cases  in 
which  the  condition  had  existed  for  a  week.  During  convalescence 
the  dilatation  may  retrograde  and  the  heart  confines  return  to  their 
normal  limits. 

Auscultation. — In  the  majority  of  case?,  a  soft  systolic  murmur 
is  heard  over  the  apex  and  the  mitral  area.  There  is  rarely  a  pre- 
systolic murmur.  There  may  be  murmurs  at  the  other  valves,  having 
the  characteristics  of  the  same  murmurs  in  the  adult. 

In  any  acute  disease,  the  physician  should  be  careful  to  observe 
a  murmur  very  carefully  before  pronouncing  it  organic.  I  have 
found  murmurs,  especially  in  typhoid  and  scarlet  fever  in  young  and 
older  children,  which  appeared  and  disappeared.  Such  murmurs  are 
haemic  or  myocarditic  and  functional ;  they  are  very  gentle,  generally 
systolic,  and  are  limited  very  closely  to  the  apex  or  pulmonic  area. 
They  are  not  conducted  and  there  are  no  positive  signs  of  dilatation. 
Jacobi  has  described  pulmonic  murmurs  in  very  young  infants,  which 
were  at  autopsy  shown  to  be  functional.  On  the  other  hand,  if  a 
murmur  is  distributed  over  a  valvular  area,  takes  the  place  of  the 
valvular  sound,  is  conducted  into  the  arteries,  and  occurs  in  conncc- 


DISEASES  OF  THE  EEAET. 


G95 


tion  witii  signs  of  dilatation,  the  physician  is  justified,  acute  symptoms 
being  in  evidence,  in  assuming  the  presence  of  organic  disease- 
Course  and  Prognosis. —  Many  cases  of  endocarditis,  especially 
those  not  of  rheumatic  origin,  run  their  course,  do  not  recur,  and  in 
after-life  give  no  symptoms  referable  to  the  heart.  Others  run  an 
acute  course  without  developing  any  physical  signs  until  convales- 
cence. I  have  seen  such  forms  follow  chorea.  The  murmur  develops 
in  the  intervals  of  freedom  from  symptoms  of  chorea.  Rheumatic 
cases  are  likely  to  recur,  and  in  this  tendency  lies  the  danger.  The 
prognosis  as  to  immediate  recovery  is  very  good  in  all  of  the  ordi- 
narily severe  cases  of  acute  endocarditis.  The  severer  septic  or 
malignant  cases  give  a  grave  prognosis.     The  future  of  cases  of  acute 


Fig. 

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Recurrent  endocarditis   with  acute  articular  rlieumatism  which  developed  under   obser- 
vation.    Boy,  twelve  years  of  age. 


endocarditis  which  have  recovered  will  depend  very  much  on  the 
immediate  management.  I  have  seen  patients  who  had  been  allowed 
to  be  up  and  about  too  early  and  to  participate  in  sports,  develop  after 
a  few  months  symptoms  resembling  those  seen  in  acute  dilatation  due 
to  heart  strain.  These  cases  show  a  marked  dyspnoea  on  exertion  and 
cyanosis  after  play.  The  children  are  easily  fatigued.  They  have 
pain  and  uneasiness  over  the  region  of  the  heart  after  running.  On 
percussion  an  abnormally  large  heart  area  is  found. 

Treatment." — The  treatment  of  acute  endocarditis  is  directed  toward 
limiting  the  damage  done  by  the  disease  to  the  heart.  Rest  in  bed  is 
necessary.  The  patient  should  not  be  allowed  to  maintain  the  sitting 
posture,  but  should  be  recumbent.  The  rest  should  be  continued 
long  ofter  the  subsidence  of  the  active  symptoms.  The  symptoms 
and  physical  signs  are  the  guides  as  to  its  duration.  If  there  have 
been  marked  disturbance  of  the  heart  action  and  distinct  dilatation 
of  the  ventricle  with  signs  of  myocarditis  such  as  great  irregularity 
of  the  pulse,  the  stay  in  bed  should  be  prolonged  for  weeks. 

If  the  action  of  the  heart  is  rapid  and  tumultuous,  an  ice-bag 
should  be  placed  over  the  cardiac  area.  This  remedy  is  also  useful 
in  cases  in  which  the  heart  action  is  not  very  rapid,  but  in  which  there 
are  nevertheless  signs  of  active  inflammatory  disturbances. 


696 


DISEASES    OF    THE    CIBCULATOBY   SYSTEM. 


Salicylate  of  sodium  is  a  favorite  remedy,  not  only  in  cases  with 
a  rheumatic  history,  but  also  in  septic  cases.  The  dosage  is  one  grain 
combined  with  double  the  amount  of  bicarbonate  of  soda  for  every 
year  of  the  age.  Some  children  have  stomach  disturbances  after 
taking  salicylates.  There  must  then  in  the  rheumatic  cases  be  sub- 
stituted some  alkali,  such  as  bicarbonate  of  soda.  Aspirin  is  given 
in  many  cases  with  apparent  benefit.  A  few  drops  of  the  tincture 
of  digitalis  will  be  useful  in  regulating  the  heart  action  late  in  the 
disease.  Digitalis  is  given  for  periods  of  a  few  days  and  then  sus- 
pended for  a  time,  after  which  it  may  again  be  given  if  necessary. 
Care  should  be  taken  to  support  but  not  to  drive  the  heart.  The  diet 
should  be  light,  fluid,  and  easily  assimilable.  The  bowels  are  best 
regulated  with  some  saline  cathartic  or  rectal  enemata. 

Fig.  158. 


10  11  12  13  14       t5'5' 


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Fatal  septic  endocarditis  following  a  pneumonia.      Streptococci  found  by  culture  in  the 
blood  during  life.     Girl,   eigbt  years  of  age. 


The  temperature,  if  high,  may  be  treated  in  the  same  way  as  in 
other  acute  diseases.  Baths  of  low  temperature  should  not  be  given. 
The  temperature  in  this  disease  is  of  so  short  duration  that  in  the 
majority  of  cases  sponging  with  cold  water  is  effective.  The  man- 
agement of  choreic  cases  will  be  discussed  in  the  section  on  Chorea. 

Septic,  Ulcerative,  or  Malignant  Endocarditis. — This  form  of 
endocarditis  is  rare  in  infants  and  children.  Adams  collected  47 
cases  in  children.  The  sexes  Avere  about  equally  affected.  Three 
cases  were  congenital  and  8  were  five  years  of  age  or  under.  The 
others  ranged  up  to  fourteen  years.  The  trend  of  opinion  (Adams) 
supports  the  contention  of  Lazarus,  Barlow,  and  Weichselbaum,  that 
these  cases  differ  from  the  benign  cases  only  in  degree  of  severity. 
Dreschfeld  divides  these  cases  into  the  following  classes:  (a)  the 
primary  form,  (h)  the  form  complicating  septic  disease,  (c)  the  form 
complicating  pncnmoriia  and  meiuiigitis,  (d)  the  form  which  occurs 


DISEASES  OF  THE  HEAET. 


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698  DISEASES    OF    THE    CIECULATOBY   SYSTEM. 

as  a  mixed  infection  due  to  septic  organisms  in  the  acute  infectious 
fevers  or  which  is  secondary  to  the  rheumatic  affections  of  the  valves. 

Symptoms.- — In  one  of  my  cases  occurring  in  a  boy  with  osteomye- 
litis of  the  tibia,  staphylococci  were  found  in  the  blood  during  life. 
In  another  case,  which  followed  a  pneumonia,  streptococci  were  found 
in  the  blood  during  life.  In  the  former  case  hemorrhagic  symptoms 
and  signs  of  severe  cardiac  disease,  such  as  gallop-rhythm  were 
observed. 

The  latter  case  was  seen  in  my  hospital  service.  The  child,  a 
girl  of  eight  years,  had  had  a  pneumonia  three  weeks  previous  to  her 
admission.  She  had  apparently  recovered,  had  sat  up  in  bed  after 
ten  days,  and  was  about.  A  day  before  her  admission  the  tempera- 
ture mounted  to  104°  F.  (40°  C),  she  vomited,  and  had  diarrhoea. 
The  child  showed  much  prostration,  and  on  examination  an  area  of 
consolidation  was  found  in  the  right  lung  behind.  She  had  an  active 
endocarditis  giving  a  mitral  systolic  murmur.  The  liver  and  spleen 
were  large;  the  temperature  rose  and  fell  twice  daily,  chills  and 
dyspnceic  attacks  preceding  each  rise.  The  temperature  subsided  to 
the  normal  or  subnormal  after  each  rise.  There  were  nausea,  vomit- 
ing, and  signs  of  cardiac  failure.  The  heart  did  not  at  first  show 
any  enlarged  area  of  dulness.  After  a  few  days  the  left  ventricle 
showed  an  increased  area  of  dulness  to  the  extent  of  2  to  3  centimetres 
outside  the  nipple-line  (acute  dilatation),  with  diffusion  of  the  apex- 
beat.  The  right  ventricle  was  dilated.  With  the  extreme  fluctua- 
tions of  temperature,  the  child  became  delirious.  The  heart,  as  at 
the  time  of  admission,  showed  a  mitral  systolic  murmur.  After  ten 
days  petechise  appeared,  first  on  the  neck  and  upper  thoracic  region, 
and  increased  both  in  number  and  extent.  The  face  and  eyes  became 
oedematous  (cardiac  failure).  The  patient  became  unconscious  and 
died  in  coma  with  Cheyne-Stokes  respiratory  phenomena.  The 
blood  withdrawn  during  life  showed  in  culture  the  presence  of  long 
streptococci. 

I  have  seen  several  cases  of  septic  endocarditis  in  which  the  symp- 
toms were  exceedingly  mild  in  contrast  with  those  described  above. 
The  patients  showed  few  subjective  symptoms,  there  was  an  increas- 
ing anaemia,  and  they  even  wished  to  be  up  and  about.  While  there 
was  some  lassitude,  the  patients  sat  up  in  bed,  played  with  their  toys, 
and  were  in  excellent  humor.  The  rises  in  temperature  were  irreg- 
ular, rarely  exceeding  103°.  A  few  petechise  were  discoverable  on 
the  orbital  conjunctiva?.  There  were  the  physical  signs  of  endocar- 
ditis, such  as  murmurs  and  dilatation  of  the  ventricle.  These  cases 
showed  an  attenuated  form  of  Streptococcus  in  the  blood  by  repeated 
culture.  Such  cases  may  recover  or  go  on  to  more  active  symptoms 
and  death  (Fig.  159). 


DISEASES  OF  THE  HEART.  699 

Diagnosis. — The  diagnosis  of  septic  endocarditis  rests  on  the  his- 
tory and  the  presence  of  cardiac  signs,  the  prostration,  the  fluctua- 
tions in  temperature  in  severe  cases  resembling  those  in  sinus  throm- 
bosis in  ear  disease,  the  onset  of  chills  and  delirium,  the  presence 
of  petechise,  and  lastly  on  the  results  of  examination  of  the  blood 
for  bacteria. 

Of  great  interest  in  this  connection,  are  the  cases  of  chronic  recur- 
rent endocarditis  which  toward  the  close  of  the  disease  have  certain 
symptoms  resembling  those  of  the  septic  or  so-called  malignant  cases. 
In  a  child  of  ten  years  suffering  from  chronic  recurrent  rheumatic 
endocarditis,  there  was  toward  the  close  of  the  illness  a  period  during 
which  phlebitis  with  thrombosis  of  the  deep  veins  of  the  neck  and 
arms  on  both  sides  and  oedema  of  the  corresponding  extremities  devel- 
oped successively.  After  a  few  weeks  the  symptoms  of  phlebitis  and 
thrombosis  gradually  subsided  and  there  was  a  period  of  a  few  weeks 
during  which  the  patient  was  much  improved.  The  fever  and  ana- 
sarca subsided  and  the  heart  action  was  good.  Before  the  fatal  issue 
the  endocarditis  recurred  and  there  were  fever  and  what  appeared  to 
be  significant  petechise  on  various  portions  of  the  body.  The  case 
was  a  rheumatic  one  and  had  been  under  observation  for  two  years. 
Its  outcome  gives  weight  to  the  theory  that  a  seemingly  benign  endo- 
carditis may  at  any  time  take  on  a  malignant  or  septic  nature. 

Prognosis. — All  the  severer  forms  of  septic  endocarditis  give  a 
grave  prognosis.  The  milder  forms  may  make  an  apparent  tem- 
porary recovery.  Thomson  has  recently  reported  such  cases  in  adults. 
In  children  such  an  outcome  is  not  impossible  though  the  outlook  even 
in  the  mildest  forms  of  septic  endocarditis  is  always  linked  with 
uncertainty. 

Treatment. — The  treatment  of  septic  endocarditis  does  not  differ 
from  that  of  acute  endocarditis.  There  is,  however,  the  question  as 
to  the  annihilation  of  the  bacteria  in  the  blood  as  a  preliminary  to 
permanent  cure.  This  is  still  one  of  the  problems  of  internal  medi- 
cine. We  have  no  sera  or  vaccine  which  is  effective.  I  have  tried 
both  with  discouraging  results. 

Chronic  Valvular  Disease  of  the  Heart. — The  lesions  in  chronic 
valvular  disease  in  infancy  and  childhood  are  the  same  as  in  the  adult 
subject. 

Etiology. — The  etiology  has  been  considered  in  the  section  on 
Endocarditis. 

Frequency. — Of  YO  of  my  cases  of  chronic  valvular  disease,  3Y 
were  of  the  female  and  33  of  the  male  sex;  2  were  below  the  age  of 
two  years ;  24  from  the  second  to  the  fifth  year,  and  39  from  the  fifth 
to  the  tenth  year  of  life.  In  50  of  the  70  cases  the  mitral  valve  was 
involved,  causing  either  a  systolic  or  a  diastolic  murmur,  or  both. 


700  DISEASES    OF    IRE    CIECULAIOEY    SYSTEM. 

The  foUo^ring  table  will  give  an  idea  of  the  relative  frequency  of  the 
valvular  lesions : 

3Iitral  insuffioiency 26  cases. 

Mitral  stenosis 6     '" 

Mitral  insufficiency  and  .stenosis 18 

Aortic  stenosis      6     " 

Aortic  stenosis  and  insufficiency 1  case. 

Endocardial  and  pericardial  disease o  cases. 

Combined  lesions  of  mitral  and  aortic  valves 8     " 

Physical  Signs. — The  physical  signs,  the  reservations  noted  in  the 
section  on  cardiac  murmnrs  being  made,  are  the  same  as  in  the  adult 
subject.  On  the  other  hand,  certain  characteristics  of  the  disease  in 
childhood  are  not  common  to  the  adult  subject.  There  are  cases  of 
chronic  cardiac  disease  in  infancy  and  childhood  which  escape  recog- 
nition because  the  heart  is  not  examined  with  sufficient  care.  Mur- 
murs of  mild  intensity  pass  unrecognized. 

There  are  cases  of  endocarditis  which  run  an  obscure  course,  give 
very  few  symptoms,  and  which  are  apt  to  recur  at  the  onset  of  tonsil- 
litis or  an  attack  of  influenza.     These  cases  of  chronic  endocardial 
y        ^  disease  give  very  few  symptoms 

in  the  intervals  between  the  at- 
tacks. There  may  be  obscure 
pains  in  the  limbs  or  joints 
which  are  not  interpreted  by  the 
physician  as  purely  rheumatic, 
but  are  believed  to  be  of  a  grip- 
pal character.  The  patients  may 
eventually  develop  symptoms  of 

Simple  mitral   insufficiency;   dilatation   of         cprimits       nnrrlinr'       i-ncn-ffipip-nr^v 
the  left  ventricle.    Girl,  six  years  of  age.  &eiiuut>       LdiUidO       iiib UiucieiltA  . 

The  cases  of  chronic  valvular 
disease  resulting  from  an  attack  of  some  infectious  disease  may  leave 
the  heart  little  compromised.  It  is  true  that  upon  examination  there 
is  a  cardiac  murmur,  but  the  cases  reveal  no  subjective  symptoms. 

They  have  what  is  called  a  healed  endocarditis.  They  may,  how- 
ever, develop  serious  cardiac  symptoms  at  the  onset  of  an  infection 
of  the  intestine  or  other  organs.  The  heart  in  these  cases  may  be 
called  irritable.  The  patients  do  not  develop  inflammation  of  the 
endocardium  or  pericardium  as  do  the  rheumatic  cases.  On  slight 
disturbance  of  the  intestines,  such  a  heart,  even  when  there  is  no 
fever,  acts  very  much  like  a  hypertrophied  organ.  There  is  an  in- 
crease not  only  of  the  frequency,  but  also  of  the  force  of  the  heart's 
impulse.  The  vessels  are  also  affected,  and  there  is  a  bounding  full 
pulse  at  the  radial.  As  a  result  of  the  infection  and  of  the  congestion 
brought  about  by  the  increased  action  of  the  heart,  there  will  be 
albumin  and  casts  in  the  urine.     These  symptoms  subside  and  do  not 


DISEASES  OF  THE  HEART. 


701 


recur  except  at  long  intervals.  In  the  intervals,  with  the  exception 
of  a  valvular  murmur,  there  are  absolutely  no  signs  of  cardiac  disease. 
In  children,  cases  v^ith  a  slight  or  marked  valvular  lesion  which 
is  apparently  at  a  standstill,  give  certain  symptoms  which  are  sig- 
nificant of  defective  cardiac  action.  On  exertion,  the  children  com- 
plain of  pain  in  the  side  or  the  epigastrium.     Examination  will  show 


Pig.  161. 


Chronic  cardiac  disease ;  dilatation  of  the  right  and  left  ventricles. 

tion.     Boy,  six  years  of  age. 


Epigastric  pulsa- 


little  change  in  the  cardiac  area.  The  valvular  murmur  is  heard. 
Such  hearts  are  also  irritable.  I  have  often  found  a  distinct  history 
of  palpitation  occurring  at  intervals  and  even  in  the  absence  of  exer- 
tion. Many  children  with  chronic  cardiac  disease  of  a  very  mild 
and  absolutely  quiescent  type,  exhibit  a  persistent  pallor  which  does 
not  yield  to  drugs.  Children  without  other  symptoms  complain  of 
headaches  after  slight  excitement.  Examination  will,  in  these  cases 
also,  show  a  slight  hitherto  unrecognized  chronic  cardiac  valvulitis. 


702 


DISEASES    OF    THE    CIECULATOEY    SYSTEM. 


Slight  oedema  of  the  eyes  which  is  persistent  should  direct  attention 
to  the  heart. 

Many  cases  without  any  other  signs  of  chronic  cardiac  disease 
show  a  slight  evanescent  trace  of  albumin  in  the  urine. 

There  may  be  absolutely  no  signs  of  cardiac  insufficiency  or  change 
in  the  physical  character  of  the  organ.     Children  with  signs  of  quies- 

FiG.  162. 


Chronic  cai-diac  disease ;  great  cardiac  dilatation ;  recurrent  attacks  of  endocar- 
ditis ;  phlebitis  and  thrombosis  of  the  deep  veins  of  the  neck  and  arm  on  both  sides 
successively ;  oedema  of  the  corresponding  arm  and  forearm ;  great  dilatation  of  the 
superficial  cervical  and  thoracic  veins.     Female,  ten  years  of  age. 


cent  cardiac  disease  often  have  obscure  attacks  of  faintness  and  vom- 
iting, following  every  little  excitement. 

The  rheumatic  recurrent  cases  of  endocarditis  in  childhood  ex- 
hibit very  much  the  same  symptoms  of  cardiac  insufficiency  as  the 
corresponding  cases  in  adults,  viz.,  enlargement  of  the  liver  aud 
spleen.     Children  ajipear  to  recuperate  more  rapidly  than  adults,  but, 


DISEASES  OF  TEE  HEART.  703 

on  the  other  hand,  the  attacks  are  more  likely  to  recur  in  them  than 
in  older  subjects.  A  compromised  heart  in  a  child  will  bear  more 
strain  than  in  an  adult.  Cases  are  frequently  seen  in  which  children 
■show  on  physical  examination  marked  chronic  disease,  but  are  not- 
withstanding exceedingly  active  and  show  no  symptoms  referable  to 
the  heart.  The  signs  of  insufficiency  of  the  cardiac  muscle  are  the 
same  in  children  as  in  the  adult.  There  is  dyspncea  on  exertion, 
slight  oedema  of  the  general  surface,  and  enlargement  of  the  liver  and 
spleen.  In  the  later  stages,  there  are  transudates  in  the  pleura  and 
abdomen.  In  some  cases,  especially  where  there  is  progressive  inter- 
stitial myocarditis  with  adherent  pericardium,  the  pleura  may  show 
unilateral  transudate. 

In  cases  of  cardiac  insufficiency,  the  pulse  is  persistently  high  or 
very  irregular.  There  is  persistent  dyspnoea.  Children  with  car- 
diac disease  suffer,  as  a  rule,  less  than  adult  subjects. 

Cardiac  angina  is  not  an  uncommon  symptom  in  cases  of  aortic 
disease.  It  is  present  in  cases  in  which  there  are  signs  of  lack  of 
compensation.  The  angina  comes  on  in  attacks  occurring  chiefly  at 
night,  and  is  very  severe.  I  have  seen  a  boy  of  eight  years  with  an 
aortic  murmur  suffer  from  these  attacks  for  days.  In  such  cases  there 
are  a  dilated  ventricle  and  an  enlargement  of  the  liver  and  spleen. 

Prognosis. — The  prognosis  of  chronic  valvular  disease  in  childhood 
depends  very  much  on  the  type  of  disease.  If  the  heart  is  only 
slightly  affected  and  the  patient  not  a  rheumatic  subject,  the  outlook 
is  good.  With  careful  management  all  ill  after-effects  can  be  avoided ; 
children  thus  affected  may  grow  to  adult  life  without  suffering  from 
any  symptoms  referable  to  the  heart.  If,  on  the  other  hand,  they  are 
attacked  by  any  intercurrent  disease,  such  as  scarlet  fever,  the  heart 
may  again  become  the  seat  of  inflammatory  processes.  The  patients 
may,  however,  recover  and  continue  free  from  symptoms  for  years. 
The  rheumatic  cases  give  the  most  unfavorable  prognosis.  These 
are  prone  to  recurrent  attacks  of  endocarditis,  each  attack  leaving  the 
heart  in  a  more  weakened  condition  than  before.  Most  of  my  cases 
have  been  children  who,  having  had  one  attack  of  rheumatic  endo- 
carditis, suffered  from  the  affection  to  a  greater  or  lesser  degree  for 
years.  Within  a  few  years  of  the  first  attack  they  succumb  to  pro- 
gressive non-compensatory  cardiac  disease. 

Treatment. — Many  cases  of  cardiac  disease  in  infancy  and  child- 
hood give  no  symptoms  and  need  very  little  treatment  beyond  careful 
and  judicious  management.  Children  thus  affected  should  have  a 
carefully  regulated  dietary,  and  should  not  indulge  in  sports  which 
subject  the  heart  to  strain.  They  should  not  ride  the  bicycle,  but 
may,  however,  indulge  in  many  of  the  amusements  of  children,  such 
as  skating,  roller  skating,  swimming  to  a  moderate  degree,  and  horse- 


704  DISEASES   OF   THE   CIBCULATOEY   SYSTEM. 

back  exercise.  They  should  be  under  constant  observation,  and  when 
attacked  by  any  acute  infection,  however  slight,  should  be  put  to  bed, 
and  kept  quiet  until  long  after  convalescence.  In  these  cases  an  anti- 
rheumatic course  is  pursued  even  although  the  illness  be  only  a  mild 
attack  of  influenza  or  tonsillitis.  It  is  well  to  give  the  salicylates  in 
small  doses  for  several  days  and  to  keep  the  bowels  open  with  some 
alkaline  cathartic.  With  children  who  suffer  from  rheumatism,  the 
nature  of  the  primary  disease  should  not  be  forgotten.  They  should 
have  constant  antirheumatic  treatment  even  when  the  cardiac  disease 
is  at  a  standstill. 

Any  rise  of  temperature  should  be  regarded  as  a  threatening  sign 
and  the  patients  put  to  bed  for  perfect  rest  until  the  crisis  has  passed. 
In  cases  in  which  there  is  marked  dilatation  or  pericardial  involve- 
ment, any  exacerbation  of  symptoms  is  a  signal  for  immediate  rest 
in  bed.  Slight  oedema  of  the  surface  and  swelling  of  the  liver  and 
spleen  will  subside  if  treated  with  perfect  rest,  a  light  assimilable 
diet  (milk),  and  mild  alkaline  catharsis.  It  is  not  always  necessary 
to  use  digitalis.  If  given  at  all,  it  is  best  administered  in  the  form 
of  the  infusion  or  a  reliable  tincture.  I  am  accustomed  to  use  this 
drug  for  a  period  of  two  or  three  days,  after  which  I  discontinue  it. 

In  some  cases  of  uncontrollable  vomiting  the  digitalis  may  effect- 
ually be  given  in  form  of  infusion  by  the  rectum.  There  is  no  doubt 
that  its  action  continues  after  the  administration  is  stopped.  Con- 
vallaria  in  the  form  of  the  fluid  extract  is  at  times  one  of  the  most 
useful  remedies  in  cases  in  which  digitalis  has  failed  to  give  relief. 
If  there  is  great  dyspnoea  or  orthopnoea,  codeia  in  moderate  doses 
should  be  used. 

Young  children  do  not  bear  morphine  well.  It  certainly  should 
not  be  used  hypoderm-atically.  Nitroglycerin  in  doses  of  grain  Moo 
(0.0006)  relieves  the  angina.  In  aortic  disease,  I  administer  mor- 
phine only  to  older  children,  and  then  only  when  the  nocturnal 
attacks  of  angina  are  very  severe.  In  young  children  with  irritable 
heart,  codeia  is  an  exceedingly  useful  remedy.  I  have  not  found 
strychnine  very  useful  in  the  chronic  forms  of  cardiac  disease.  Caf- 
feine in  moderate  dosage  seems  more  useful  in  correcting  the  irreg- 
ularity of  the  pulse  or  bradycardia  seen  in  some  of  these  cases.  In 
combination  with  digitalis  it  gives  excellent  results.  If  ascites 
appears,  the  patient  should  be  promptly  tapped  to  relieve  the  circula- 
tion and  the  abdomen  supported  by  a  binder.  If  there  is  a  pleuritic 
effusion  at  the  same  time,  it  should  not  bo  disturbed.  With  relief  of 
the  abdominal  distention,  the  pleuritic  effusion  often  disappears. 

Cardiac  Murmurs. — Cardiac  murmurs  which  are  the  result  of 
disease  or  insufficiency  of  the  valves  of  the  heart  have  the  same  gen- 
eral character  as  those  in  adults,  the  following  being  the  chief  points 
of  difference: 


DISEASES  OF  THE  HEAET.  705 

a.  Cardiac  disease  of  a  very  serious  character  may  exist  (as  in 
congenital  cyanosis)  without  any  murmur. 

h.  Cardiac  murmurs  are  as  a  rule  louder  in  children  than  in 
adults.  The  loudness  is  therefore  no  guide  as  to  the  seriousness  of 
the  affection. 

c.  Cardiac  murmurs  in  children  are  sometimes  heard  conducted 
over  the  whole  chest;  diagnosis  of  disease  of  a  particular  valve  must 
be  based  on  the  greatest  intensity  of  the  murmur  at  that  point. 

d.  Hsemic  and  dynamic  murmurs  in  children  under  four  years 
of  age  are  not  so  common  as  is  supposed.  There  should  be  no  hesita- 
tion in  making  the  diagnosis  of  organic  affections  in  systolic,  basic, 
or  apex  murmurs  if  there  are  distinct  conduction  or  signs  of  dilata- 
tion or  hypertrophy.  This  is  especially  to  be  remembered  in  chorea, 
extreme  anaemia,  and  in  febrile  affections  where  rapidity  in  time  and 
rhythm  (gallop-rhythms)  causes  adventitious  sounds. 

e.  The  conduction  of  the  aortic  murmurs  into  the  arteria  femor- 
alis  occurs  in  occasional  cases  in  children.  Pulsation  of  the  liver  or 
spleen,  as  found  in  aortic  disease  of  adults,  is  rare  in  children 
(Steffen). 

The  peculiarities  of  the  aortic  pulse  and  so-called  pistol-shot 
sound  in  the  femorals  are  observed  in  children  as  in  adults. 

Accidental  Cardiac  Murmurs. — Accidental  murmurs  are  divided 
into  those  heard  over  the  heart,  in  the  arteries,  and  in  the  veins.  The 
study  of  the  accidental  murmur  of  the  heart  in  infancy  and  childhood 
has  been  much  neglected.  West  and  Hochsinger  give  the  most  val- 
uable data.  The  principal  points  of  difference  between  the  murmurs 
in  infants  and  children  and  those  in  the  adult  are  as  follows : 

Cardiac  Murmurs. — Anwmia. — The  severest  forms  of  anaemia  in 
my  experience  sometimes  fail  to  give  hsemic  murmurs.  !N^ot  one  of 
200  cases  under  four  years  of  age  examined  by  Hochsinger  gave 
anaemic  murmurs.  After  the  fourth  year  and  up  to  the  seventh  year 
of  life  the  frequency  of  the  anaemic  and  haemic  murmurs  increases. 
I  have  in  cases  of  pernicious  anaemia  found  a  mild  blowing  basic 
murmur.      One  such  case  occurred  in  a  child  under  four  years. 

Fevers. — The  hsemic  murmurs  so  common  in  the  febrile  affections 
of  adult  life  are  rarely  heard  even  in  severe  febrile  affections  with 
anaemia,  in  patients  under  the  age  of  three  years.  I  have  heard 
hsemic  murmurs  in  children  under  three  years  of  age,  with  severe 
typhoid  fever.     They  are  common  in  typhoid  fever  in  older  children. 

Characteristics  of  Anwmic  Murmurs. — These  never  occur  with 
signs  of  cardiac  dilatation  or  hypertrophy.  They  are  not  conducted 
into  the  arteries.  They  never  entirely  take  the  place  of  the  valvular 
cardiac  sounds,  but  accompany  them.  They  are  soft  blowing  mur- 
murs, heard  at  times  most  loudly  at  the  pulmonary  valve,  sometimes 

45 


706  DISEASES    OF    TEE    CIBCULATOBY   SYSTEM. 

heard  over  the  base  and  whole  prfecordium,  and  faintly  heard  at  the 
apex.  They  are  never  heard  at  the  aortic  or  tricuspid  valves,  or 
behind.  They  are  inconstant,  disappearing  for  a  time  and  again 
appearing  at  the  various  points  in  the  chest. 

Accidental  Arterial  Murmurs.- — The  theory  held  by  some  observers, 
that  pressure  of  the  stethoscope  on  the  arteries  of  the  neck  may  cause 
a  murmur,  should  be  entertained  with  caution.  Correct  stethoscopy 
will  hardly  lead  to  such  an  error.  A  murmur  in  the  large  arteries 
of  the  neck  is  conducted  from  the  heart  and  is  invariably  organic 
in  origin.  I  have  heard  aortic  murmurs  conducted  in  the  femoral 
artery. 

Venous  Hum.  —  Although  cardiac  accidental  murmurs  due  to 
anaemia  are  rarely  heard  in  children,  the  venous  hum  due  to  the  same 
cause  is  frequently  heard.  In  young  infants  and  children  it  is  pres- 
ent in  the  veins  of  the  neck,  is  quite  loud,  and  is  heard  at  either  side 
of  the  upper  part  of  the  sternum.  If  there  is  ansemia  due  to  valvular 
cardiac  disease,  the  venous  hum  is  heard  in  the  arteries  of  the  neck, 
with  the  organic  murmur. 

Myocarditis. — Myocarditis  is  very  frequent  in  infancy  and  child- 
hood. Most  of  the  knowledge  of  this  condition  has  been  obtained 
from  a  study  of  the  disease  in  young  subjects.  This  is  due  to  the 
fact  that  in  early  life  the  heart  is  especially  exposed  to  the  deleterious 
action  of  the  toxins  of  the  infectious  diseases.  Myocarditis  is  a 
degeneration  or  inflammation  of  the  muscular  substance  of  the  heart, 
secondary  to  the  action  of  poisons  (phosphorus)  to  the  toxins  of  bac- 
teria (as  in  the  exanthemata,  typhoid  fever,  diphtheria,  pertussis, 
sepsis,  osteomyelitis),  or  to  the  changes  consequent  upon  disease  of 
the  pericardium,  or  endocardium,  of  rheumatic  or  infectious  origin. 

Etiology. — The  degenerative  or  inflammatory  changes  may  be 
caused  by  the  direct  action  of  the  bacteria  (Almquist),  but  usually 
the  influence  of  the  bacteria  themselves  is  only  slight,  since  they  do 
not  find  in  the  myocardium  a  favorable  soil  for  growth.  The  toxins 
of  these  bacteria  produced  either  elsewhere  in  the  economy  and 
circulating  in  the  blood,  or  in  the  heart  muscle  itself,  are  chiefly 
instrumental  in  causing  the  degenerative  changes  (Welch,  Flexner, 
Schamshin).  -  Fever,  as  such,  has  only  a  slight  influence  in  causing 
my ocarditi  s  ( Werhof sky ) . 

Morbid  Anatomy. ^ — If  there  is  degeneration  of  the  myocardium, 
the  muscular  fibre  may  be  the  seat  of  fatty  changes.  There  is  an 
increase  of  fat  drops  in  the  muscular  tissue  of  the  heart.  In  advanced 
conditions,  the  fatty  changes  are  apparent  to  the  naked  eye  as  a  yel- 
lowish discoloration  beneath  the  endocardium.  In  other  cases,  there 
is  a  granular  or  hyaline  degeneration  of  the  muscle  fibre  or  a  vacuole 
formation.     The  cell  protoplasm  becomes  cloudy,  hyaline,  loses  its 


DISEASES  OF  THE  HEABT.  707 

striation,  and  disintegrates  or  is  replaced  by  drops  of  fluid.  This 
occurs  in  diphtheria,  typhoid  fever,  pneumonia,  chronic  congestion, 
and  in  toxaemia  of  various  kinds.  Thrombi  may  form  in  hearts 
which  are  the  seat  of  advanced  degeneration.  In  toxaemia  and  the 
infectious  diseases,  there  is  inflammation  of  the  myocardium.  There 
is  an  invasion  of  the  muscle  tissue  by  bacteria  from  the  endocardium 
(staphylococci,  streptococci,  and  pneumococci).  In  such  cases,  there 
are  also  grayish  or  yellowish  discoloration  of  the  muscle  tissue,  vacuo- 
lization, and  granular  and  hyaline  degeneration.  The  muscle  tissue 
is  the  seat  of  small  cell  infiltration  or  there  may  be  abscesses  of  micro- 
scopic or  macroscopic  size.  If  recovery  occurs  these  areas  may  cica- 
trize with  formation  of  connective  tissue.  Tuberculous  and  syphilitic 
inflammations  of  the  myocardium  occur,  but  are  rare. 

Symptoms. — The  symptoms  of  myocarditis  can  best  be  understood 
by  studying  the  heart  in  the  various  infectious  diseases.  In  diph- 
theria, myocarditis  may  be  suspected  if  there  occur  sudden  syncope, 
faintness,  chilly  sensations,  vertigo,  and  vomiting.  The  patients 
complain  of  prsecordial  weakness ;  there  are  all  the  symptoms  of  col- 
lapse and  a  flickering,  irregular  pulse.  These  phenomena  may  appear 
at  intervals  throughout  the  disease  and  persist  far  into  convalescence. 
In  this  disease  there  is  during  convalescence  an  irregularity  of  the 
heart  apparent  in  the  rhythm  and  force.  There  will  be  two  or  three 
beats  and  then  an  interval,  followed  by  two  or  three  beats.  The 
pulse  at  the  wrist  may  be  of  varying  compressibility.  In  these  cases 
there  may  be  no  other  manifestation  of  the  effect  of  the  poison  of  the 
disease  on  the  heart-muscle  and  ganglia.  There  is  no  pain,  no  vom- 
iting, no  prsecordial  distress,  yet  for  days  the  heart-action  will  remain 
irregular  and  cause  great  uneasiness  to  the  physician.  Such  cases 
may  make  a  good  recovery. 

In  some  exceptional  cases,  however,  these  symptoms  precede  more 
serious  disturbances  of  a  severe  and  even  fatal  character.  The  forms 
of  marked  cardiac  irregularity  are  especially  disquieting  if  observed 
during  or  after  diphtheria,  even  of  a  mild  type.  In  these  cases  the 
physician  is  ill  at  ease  on  account  of  the  well-known  occurrence  of 
sudden  death  in  this  disease.  I  have  seen  irregularity  persist  in  these 
cases  for  weeks,  to  disappear  finally ;  and  yet  during  all  this  time  the 
physician  can  give  no  positive  assurance  that  the  case  may  not  result 
fatally.  Simple  irregularity,  as  a  rule,  without  signs  of  true  mus- 
cular weakness  of  the  heart,  such  as  swelling  of  the  liver  or  dilatation 
of  the  ventricle,  retrogrades  to  the  normal. 

The  toxic  myocarditis  complicating  diphtheria  manifests  itself  in 
two  forms:  the  slow  irregularly  acting  heart  and  the  rapidly  acting 
organ.  In  those  cases  in  which  the  heart-action  is  rapid,  the  eff"ect 
of  the  toxin  is  manifested  in  a  rapid  tumultuous  action  from  the  out- 


708  DISEASES    OF    TEE   CIECULATOBY    SYSTEM. 

set.  The  pulse  is  thready,  demonstrating  the  ineffective  driving- 
power  of  the  heart  and  great  muscular  weakness  of  that  organ.  The 
orthopnoea  is  great  and  there  is  swelling  of  the  liver  with  epigastric 
pain  and  vomiting. 

In  acute  forms  of  pneumonia  in  which  the  toxaemia  is  very  great, 
infants  may,  even  at  the  outset,  exhibit  cardiac  weakness.  There  are 
slight  cyanosis  of  the  lips  and  abnormal  pallor  of  the  face  and  gen- 
eral surface.  The  heart  action  is  more  rapid  than  in  other  cases  of 
pneumonia  in  which  the  lung  lesion  is  quite  as  extensive.  At  the 
crisis,  the  action  of  the  poison  on  the  heart  is  evinced  l)y  an  irregu- 
larity or  arrhythmia  of  the  pulse.  The  pulse  may  be  extremely  slow 
(bradycardia).  In  septic  conditions  there  will, late  in  the  disease.be 
gallop-rhythm,  distortion  of  the  pulse-respiration  ratio,  cyanosis,  and 
extreme  prsecordial  distress.  Henoch,  Osier,  and  the  writer  have  shown 
that  there  may  be  degenerative  changes  in  pertussis.  These  are  clini- 
cally apparent  in  cases  which  have  extended  over  a  long  period.  A 
constant  dyspnoea,  an  abnormally  high  pulse-rate,  drowsiness,  disin- 
clination to  exertion,  and  slight  oedema  of  the  face  and  other  parts 
of  the  body  are  present.  In  rare  cases  physical  examination  reveals 
a  slight  dilatation  of  the  right  ventricle.  In  other  cases  there  is  at 
the  apex  a  faint  systolic  murmur  of  purely  muscular  origin.  In 
adherent  pericardium,  the  advance  of  the  process  into  the  myocardium 
is  indicated  by  the  symptoms  above  detailed. 

The  myocarditis  of  chronic  valvular  disease  is  a  progressive 
process.  It  manifests  itself  by  the  signs  of  lack  of  comj^ensation 
described  in  the  section  on  Chronic  Valvular  Disease.  The  varying 
pulse,  the  dyspnoea,  the  enlargement  of  the  liver  and  spleen,  and 
transudates  into  the  serous  cavities,  all  indicate  this  form  of  progres- 
sive weakness  of  the  cardiac  muscle. 

Diagnosis. — Although  the  diagnosis  cannot  in  all  cases  be  made 
with  a1>solute  certainty,  the  presence  of  the  condition  may  be  sus- 
pected if  the  following  sets  of  symptoms  appear  at  regular  intervals 
in  the  course  of  the  disease — attacks  of  palpitation  and  faintness, 
pallor,  cardiac  irregularity,  gallop-rhythm  and  weakness  of  the  apex 
beat  and  of  the  first  muscular  sound  of  the  heart,  with  intensification 
of  thf  second  pulmonic  sound. 

Treatment. — The  treatment  should  sii])])ort  the  heart  and  lessen  its 
work,  and  should  also  be  directed  toward  the  management  of  the 
primary  condition.  In  all  of  these  cases,  ])rolonged  rest  for  the  heart, 
continued  long  after  convalescence,  is  of  primary  importance.  It 
should  not  be  forgotten  that  even  in  a  degenerated  organ  there  is 
healthy  tissue  on  which  the  drugs  and  treatment  act.  These  healthy 
foci  should  be  sustained,  and  not  exhausted  by  the  action  of  powerful 
drugs  given  in  large  doses.  Degeneration  cannot  be  cured  by  drugs; 
nature  must  heal  the  diseased  areas. 


DISEASES  OF  TEE  HEART.  709 

Cardiac  irregularity,  pure  and  simple,  with  a  pulse  of  moderate 
slowness,  is  best  treated  by  means  of  strychnia  and  caffeine.  To  a 
child  of  three  or  four  years  of  age,  strychnia,  %oo  grain,  is  given 
with  or  without  a  grain  of  caffeine  every  three  hours.  Warmth  is 
applied  to  the  heart,  and  if  the  extremities  are  cold,  warm  bottles  are 
applied  also.  Camphor  is  a  very  excellent  remedy,  but  can  only  be 
used  for  a  short  length  of  time,  for  it  is  badly  born©  by  the  stomach, 
and  in  such  cases  must  be  used  hypodermically.  Oil  of  camphor,  30 
minims,  may  be  given  to  a  child  three  years  of  age. 

Severe  cases  accompanied  by  a  gallop-rhythm  are  treated  with 
talis.  This  drug  is  an  excellent  remedy  in  these  cases,  but  must  be 
used  cautiously,  in  small  doses.  To  a  child  of  three  or  four  years  of 
age,  TlXij  of  the  tincture  of  digitalis  given  every  three  hours  is  suffi- 
cient. If  restlessness  or  vomiting  appear,  morphia  is  our  only  safe- 
guard, but  should  be  used  cautiously.  Enough  only  is  given  to  quiet 
the  patient.  One  or  two  minims  of  Magendie's  solution  is  given  by 
the  mouth  to  a  child  three  to  five  years  of  age. 

Hypertrophy  and  Dilatation  of  the  Heart. — Cardiac  hypertrophy 
and  dilatation,  combined  or  singly,  and  without  any  valvular  lesion, 
occur  in  isolated  cases  in  childhood.  The  condition  is  rare  before 
the  fifth  year.  A  number  of  cases  occurring  between  the  fifth  and 
the  tenth  year  have  been  reported.  If  hypertrophy  alone  is  present, 
it  may  affect  the  left  ventricle  only,  or  both  ventricles.  Dilatation 
usually  affects  first  the  right  and  then  the  left  ventricle.  The  condi- 
tion develops  as  a  result  of  toxsemic  influences,  in  the  acute  infectious 
diseases,  such  as  scarlet  fever,  pneumonia,  diphtheria,  and  typhoid 
fever. 

Hypertrophy,  with  or  without  dilatation,  is  one  of  the  sequelae  of 
acute  or  chronic  nephritis.  The  nephritis  complicating  scarlet  fever 
is  frequently  the  cause  of  cardiac  hypertrophy  with  or  without  dila- 
tation. Arterio-sclerosis  with  diminution  of  the  calibre  of  the  aorta 
may  cause  hypertrophy  with  or  without  dilatation.  I  have  seen  sev- 
eral of  such  cases  in  children.  Acute  dilatation  as  a  result  of  heart 
strain  is  rare  in  children. 

Symptoms. — The  symptoms  are  not  characteristic.  In  the  absence 
of  all  other  heart  lesions,  the  diagnosis  of  cardiac  hypertrophy  or 
dilatation  is  made  from  the  physical  signs.  These  do  not  differ  from 
those  found  in  the  adult  subject.  The  rational  symptoms  also  resem- 
ble those  of  the  adult.  In  dilatation  of  the  heart,  there  are  the  irreg- 
ular heart  action,  the  dyspnoea  or  orthopnoea,  the  pallor  of  the  surface, 
cyanosis,  and  in  the  later  stages  swelling  of  the  liver  and  spleen. 
Transudates  in  the  pleural  and  abdominal  cavities  are  apt  to  occur 
toward  the  close.  Sudden  death  has  occurred  in  some  eases  of  dila- 
tation of  the  acute  variety.     In  hypertrophy,  the  symptoms  closely 


710  DISEASES    OF    THE    CIRCULATOBY   SYSTEM. 

resemble  those  just  detailed.  At  the  bedside,  the  diagnosis  of  hyper- 
trophy, of  dilatation,  or  of  both,  must  of  necessity  rest  on  the  physical 
signs. 

Treatment. — The  treatment  varies  with  the  nature  of  the  primary 
disease  present.  The  nephritis  should  be  treated  and  the  heart  will 
take  care  of  itself.  If  there  is  an  infectious  disease,  such  as  typhoid 
fever,  diphtheria,  or  scarlet  fever,  both  the  heart  and  the  primary 
affection  should  be  treated. 


SECTION  X. 

GENERAL  CONSTITUTIONAL  DISEASES. 

DIABETES  MELLITUS. 

Diabetes  mellitus  is  of  very  rare  occurrence  in  infancy  and  child- 
hood. Simon  says  that  he  has  met  it  in  nurslings,  but  Monti  doubts 
whether  it  can  occur  under  the  age  of  one  year.  In  all  his  experience 
he  has  never  seen  such  a  case,  Leroux,  quoted  by  Monti,  collected 
147  cases  of  diabetes  in  children.  The  majority  occurred  between 
the  fifth  and  tenth  years.  Of  159  cases  collected  by  Saundby,  129 
occurred  between  these  years.  Cotton  has,  in  a  recent  article,  shown 
that  in  children  the  ratio  of  deaths  from  diabetes  to  the  whole  death- 
rate  is  0.04  per  cent,  in  Chicago,  and  1.2  per  cent,  in  ]^ew  York  City. 

Etiology. — The  etiology  of  diabetes  in  children  is  practically  the 
same  as  in  the  adult  subject.  Frerichs,  Blanchard,  Pavy,  and 
Roberts  have  shown  that  heredity  plays  an  important  role.  In  a  case 
coming  under  my  observation  a  sister  of  the  patient  had  died  of  dia- 
betes and  four  members  of  the  family  on  the  mother's  side.  In  an 
instance  reported  by  Roberts,  8  children  of  the  family  had  died  of 
it.  It  appears  that  in  certain  families  there  is  a  tendency  to  con- 
tract diabetes.  There  is  no  ground  for  assuming  that  diabetes  in 
children  follows  traumatism  or  the  infectious  diseases,  such  as  scarlet 
fever,  measles,  diphtheria,  etc.,  any  more  frequently  than  in  the  adult. 
In  some  statistics,  the  sexes  are  shown  to  be  equally  affected.  In 
others  the  disease  is  given  as  more  prevalent  in  one  or  the  other. 
Lemonnis  has  seen  diabetes  complicate  congenital  syphilis,  tubercu- 
losis of  the  lungs  and  of  the  mesenteric  lymph-nodes.  I  have  had  a 
case  complicated  with  tuberculosis  of  the  mesenteric  lymph-nodes. 

Symptoms. — The  symptoms  of  diabetes  in  children,  as  given  in  the 
cases  thus  far  published,  do  not  extend  over  so  great  a  period  as  in 
the  adult.  The  cause  of  this  must  lie  in  the  fact  that  there  is  a  long 
period  during  which  the  symptoms  are  slight  or  escape  notice.  In  a 
case  which  recently  came  under  my  care  the  child,  nine  years  of  age, 
showed  symptoms  only  five  months  before  she  came  under  observa- 
tion. At  that  time  the  mother  noticed  that  the  appetite  was  voracious 
and  that  there  were  great  thirst  and  frequent  urination.  In  spite  of 
the  large  quantity  of  food  and  liquid  taken,  the  child  lost  in  weight. 
The  amount  of  urine  passed  may  be  quite  large.  In  Cotton's  case  it 
reached  104  ounces,  in  mine  70  ounces  daily.     Monti  has  seen  as 

711 


712  GENERAL  CONSTITUTIONAL  DISEASES. 

mucli  as  16  litres  passed  in  twenty-four  hours.  Heubner  and  Hirsch- 
sprung found  that  the  daily  excretion  of  sugar  may  be  from  30  to  113 
grammes  to  the  litre. 

In  most  of  the  cases  recorded  there  has  been  polydipsia.  The  skin  is 
sometimes  the  seat  of  a  lichen-like  eruption  which  causes  intolerable 
itching.  Furuncles  and  boils  are  also  of  common  occurrence.  The 
urine  may  contain  albumin,  and  hyaline  and  granular  casts.  In  one 
of  my  cases  albumin  was  present,  but  no  casts.  There  is  as  a  rule 
constipation.  The  temperature  may  be  normal  or  subnormal.  If 
there  is  complicating  tuberculosis,  there  will  be  a  slight  daily  rise 
of  temperature  toward  evening.  In  all  the  cases  thus  far  published 
there  was  progressive  emaciation.  Acetone  in  the  odor  of  the  breath 
and  diabetic  coma  preceded  by  intervals  of  delirium  close  the  clinical 
course  of  the  disease. 

Diagnosis. — The  methods  of  diagnosis  do  not  vary  from  those  pur- 
sued in  the  adult.  The  urine  of  a  child  suifering  from  polyuria, 
polydipsia,  a  voracious  appetite,  pruritus,  and  progressive  emaciation, 
should  be  carefully  examined  for  sugar.  Infants  who  take  foods  such 
as  malted  milk,  containing  an  enormous  quantity  of  sugar,  often  show 
a  temporary  glycosuria,  which  should  not  be  mistaken  for  true  dia- 
betes, and  which  is  not  attended  by  any  of  the  clinical  symptoms  of 
that  disease  (Epstein,  Koplik). 

Treatment. — The  treatment  of  diabetes  in  children  does  not  differ 
from  that  of  the  adult,  but  I  have  been  impressed  with  the  necessity 
of  keeping  these  patients  in  bed  during  the  treatment,  as  it  is  impos- 
sible otherwise  to  observe  the  patient  or  follow  out  details  of  dietary. 

DIABETES  INSIPIDUS. 

(Polyuria.) 

This  is  rare  in  infancy  and  childhood.  If  the  daily  amount  of 
urine  is  three  or  more  times  the  normal  amount,  there  is  polyuria. 
The  specific  gravity  of  the  urine  does  not  exceed  1006.  Epstein  col- 
lected 10  cases  in  which  the  symptoms  developed  as  a  result  of  a 
cerebral  inflammation  in  the  vicinity  of  the  fourth  ventricle.  The 
aft'cction  is  sometimes  hereditary.  Cases  have  followed  fright,  the 
infectious  diseases,  meningitis,  and  traumatism.  The  cause  is  fre- 
quently obscure.     The  onset  may  be  gradual  or  acute. 

Symptoms. — Sometimes  intense  thirst  or  nervous  symptoms  usher 
in  the  disease.  The  nnti'ition  may  bo  maintained  for  years.  The 
skin  is  dry,  the  body  temperature  below  normal,  and  the  symptoms  do 
not  differ  from  those  manifested  in  the  adult.  The  following  case 
from  my  clinic  was  ])ul)lishe(l  by  my  assistant,  T)r.  Lewi: 

Walter  A.,  a?t.  seven  years,  was  first  seen  at  the  dispensary.     The 


DIABETES  INSIPIDUS.  713 

family  history  was,  for  the  most  part,  negative,  except  that  three 
children  had  died  of  nervous  diseases,  one  of  them,  aged  three  years, 
of  spinal  meningitis,  and  tv^^o  others,  v^hen  babies,  of  convulsions. 
The  patient  when  a  baby  was  healthy;  he  was  breast-fed  one  year 
and  had  never  had  a  convulsion.  When  two  years  old  he  had  vari- 
cella, followed  by  pertussis ;  at  the  age  of  five  he  had  measles,  compli- 
cated with  an  obstinate  conjunctivitis,  but  recovered.  In  October, 
1892,  while  driving,  he  was  thrown  from  a  carriage  in  rapid  motion, 
striking  the  right  side  of  the  head ;  no  ill  effects  were  noticed  at  the 
time.  In  January,  1893,  he  began  to  complain  of  pain  in  the  back 
and  in  the  nape  of  the  neck.  At  about  the  same  time  it  was  noticed 
that  he  arose  several  times  at  night  to  urinate,  and  would  invariably 
drink  water  after  micturition ;  the  mother  noticed  that  he  grew  very 
nervous ;  the  frequent  micturition  and  increased  thirst  gradually  be- 
came noticeable  during  the  day,  becoming  so  persistent  that  he  was 
obliged  to  leave  school.  He  was  placed  in  a  hospital,  where  he  re- 
mained seven  months ;  while  there  he  lost  flesh ;  none  of  the  symptoms 
improved.  He  was  on  a  rigorous  milk  diet  during  the  entire  time. 
January  19,  1894,  the  child  complained  of  pain  on  the  right  side 
of  his  head  and  felt  chilly  all  the  time  and  could  not  stand  still  a 
moment.  His  face  is  pale  and  has  an  old  person's  look,  with  features 
sharp  and  pinched.     The  eyes  are  large  and  prominent,  and  the  veins 


Date. 

Sp.  grav. 

Amount  in  24  hours. 

TTrea. 

Jan.  25. 

1.003 

6.300  c.c. 

6.3 

grammes 

Feb.     4. 

1.003^ 

6.300    " 

6.8 

(( 

6. 

1.005 

5.200    " 

7.2 

li 

8. 

1.002 

7.000    " 

6.5 

(t 

"       10. 

1.004 

5.500    " 

6.8 

ti 

"      17. 

1.002^ 

7.500    " 

7.8 

11 

"      24. 

1.003 

6.400    " 

6.5 

(< 

Mar.  18. 

1.003 

7.000    " 

8. 

" 

"       30. 

1.003 

7.300    " 

7. 

a 

Apr.     2. 

1.003J 

6.400    " 

6.8 

<i 

of  the  forehead  dilated.  The  skin  is  exceedingly  dry.  The  head  is 
well  shaped ;  careful  palpation  shows  no  sensitive  spots.  The  chest  is 
emaciated,  with  a  slight  rachitic  girdle.  The  lungs,  on  auscultation 
give  increase  of  voice-sounds  at  the  right  apex.  The  heart  is  normal, 
also  the  abdomen.  The  epiphyses  of  the  ankles  are  enlarged.  The 
glands  at  the  angles  of  the  jaw  are  enlarged,  also  those  in  the  left 
axilla. 

Urinary  Symptoms. — The  child  is  passing  a  very  large  amount  of 
urine ;  wakens  on  an  average  ten  times  a  night  to  do  so.  The  thirst 
varies  with  the  amount  of  water  passed;  for  the  last  few  weeks  he 
has  complained  of  painful  micturition.  His  appetite  is  excellent; 
he  is  on  a  milk  diet.  Weight  is  thirty-seven  pounds ;  temperature 
(per  mouth)  97.8°  F.  (36.5°  C).     The  urine  examination  was  as 


714  GENERAL  CONSTITUTIONAL  DISEASES. 

follows:  quantity  in  twenty-four  hours,  6400  c.c,  colorless;  specific 
gravity  1.003 ;  reaction  acid,  no  albumin,  no  sugar.  Microscopical 
examination  negative. 

A  series  of  quantitative  urea  tests  were  made  in  this  case.  The 
general  consensus  of  opinion  is  that  in  cases  of  diabetes  insipidus  the 
amount  of  solids,  including  the  urea,  is  increased.  The  tests  were 
made  with  the  Doremus  ureometer.  A  control  test  was  always  made. 
The  table  shows  marked  diminution  in  the  amount  of  urea.  In  order 
to  avoid  error,  fresh  bromine  was  used. 

Treatment. — The  treatment  has  been  successful  in  some  respects. 
The  child  was  at  once  put  on  a  general  diet.  Antipyrin  was  given. 
After  the  first  few  days  there  seemed  to  be  an  abatement  of  the  ner- 
vous symptoms  and  slight  diminution  in  polydipsia,  but  no  permanent 
improvement.  He  was  then  given  opium  several  weeks  without  result. 
Ergot  was  next  given,  and  continued  for  about  two  months ;  under  this 
treatment  the  pain  on  the  right  side  disappeared ;  the  restlessness 
became  less,  and  the  thirst  likewise  diminished.  Under  a  generous 
diet  the  child  held  his  ovoi. 


PLATE   XXX 


12 


•   •  * 

"■9 


10 


Topography  of  Enlarged  Lymph  Nodes. 

1.  Preauricular  nodes  enlarged,  with  disease  of  the  external  auditory  canal,  or  any  eruption 

on  the  face,  or  parotitis. 

2.  Tonsillar  nodes. 

3.  Submaxillary  nodes  enlarged,  with  disease  of  the  mouth,  or  skin  eruptions  over  the  lower  jaw. 

4.  Submental  nodes  enlarged,  with  chin  eruptions. 

5.  Retropharyngeal  nodes  enlarged,  with  infections  of  the  pharj^nx  and  the  retropharynx. 

6.  Nodes  behind  the  border  of  the  trapezius  muscle  enlarged,  with  disease  of  the  scalp. 

7.  Nodes  behind  posterior  border  of  the  sternomastoid  muscle  enlarged,  with  infections  of  the 

retropharynx  or  the  scalp. 

8.  Postauricular  nodes  enlarged,  with  ma.stoid  disease  or  scalp  infections. 

9.  Nodes  above  and  behind  the  clavicle  enlarged,  with  infections  of  the  neck  or  mediastinum. 

10.  Nodes  enlarged  in  infections  of  the  liand  or  in  eruptions  such  as  those  of  syphilis. 

11.  Axillary  nodes  enlarged,  with  infections  of  the  arm.  the  axilla,  and  the  upper  chest. 

12.  Nodes  of  the  inguinal  region  enlarged  in  infections  of  the  lower  extremity,  syphilitic  or 

other  lesions  of  the  genitals. 


SECTION  XI. 

DISEASES  OF  THE  LYMPH-NODES,  DUCTLESS 
GLANDS,  AND  THE  BLOOD. 

DISEASES  OF  THE  LYMPH-NODES. 

Ijst  any  disease  or  irritation  of  the  scalp  the  nodes  of  the  neck  may 
be  enlarged  behind  the  border  of  the  sternomastoid.  The  onset  of 
some  diseases  of  infancy,  such  as  rothcln  or  rubella,  is  indicated  by 
slow  enlargement  of  these  glands.  Infection  of  the  tonsils  will  cause 
the  lymph-nodes  at  the  angle  of  the  jaw  to  enlarge  and  sometimes  to 
suppurate.  In  young  infants  and  children,  chronic  enlargement  of 
the  tonsils  with  adenoids  causes  an  enlargement  of  these  nodes.  Tu- 
berculous glands  may  occur  in  this  region.  The  post-auricular  lymph- 
nodes  enlarge  in  disease  of  the  ear  or  of  the  adjacent  parts  of  the 
scalp.  Parotitis  will  cause  a  sympathetic  swelling  of  the  lymph- 
nodes  in  front  of  the  parotid,  and  also  below  this  gland  at  the  angle 
of  the  jaw  and  beneath  it. 

Retropharyngeal  adenitis  will  cause  the  nodes  behind  the  pharynx 
to  swell  and  to  appear  at  either  side  of  the  neck  in  front  of  the  border 
of  the  sternomastoid  muscle. 

Any  eruption  on  the  chin  will  cause  an  enlargement  of  the  lymph- 
nodes  from  the  tip  of  the  chin  to  the  hyoid  bone. 

Swelling  at  the  angle  of  the  jaw  will  frequently  simulate  parotitis. 

In  certain  forms  of  congenital  syphilis  with  mucous  patches  on 
the  lips  and  at  the  angles  of  the  mouth  (rhagades)  there  is  beneath 
the  body  of  the  jaw  a  symmetrical  enlargement  of  the  lymph-nodes 
of  both  sides  (syphilitic  adenopathies).  The  lymph-nodes  of  the 
groin  will  enlarge  in  balanitis  of  the  prepuce,  syphilis,  tuberculosis 
of  the  genitals,  and  also  in  eczema  and  intertrigo  of  the  inguinal 
folds.  The  lymph-nodes  of  the  femoral  region  will  in  infants  and 
children  enlarge  or  suppurate  as  a  result  of  any  infection  of  the  foot, 
leg,  or  thigh. 

In  the  later  stages  of  tuberculosis,  either  of  the  lung  or  perito- 
neum, there  may  be  a  general  enlargement  of  the  nodes  of  the  neck, 
axilla,  groin,  and  elsewhere.  In  many  infants  and  children  of  a 
lymphatic  diathesis  (lymphatism),  the  nodes  of  the  neck  and  groin 
show  slight  enlargement.  Such  enlargements  should  not,  in  the 
absence  of  positive  signs  of  tuberculosis  elsewhere,  be  hastily  pro- 
nounced tuberculous.     After  the  exanthemata,  the  lymph-nodes  of  the 

715 


716  LTMPH-XODES,  DVCTLESS  GLAXDS  AND  BLOOD. 

neck,  groin,  and  other  regions  may  remain  slightly  enlarged.  These 
enlargements  usually  retrograde  to  the  normal  in  time,  but  if  they 
remain  rarely  give  rise  to  synaptoms. 

The  physician  should  exclude  every  possible  infection  before  con- 
cluding that  an  enlargement  of  the  lymph-nodes  in  infancy  and  child- 
hood is  of  a  tuberculous  nature.  Cases  of  rachitis  will  show  very 
slight  enlargement  of  the  lymph-nodes,  especially  in  the  inguinal 
regions.  Torms  of  anaemia,  such  as  von  Jaksch's  disease,  also  show 
these  enlarged  nodes.  The  lymph-nodes  may  be  the  seat  of  primary 
malignant  disease,  as  in  forms  of  lymphosarcomata.  In  malignant 
growths  of  the  internal  organs,  such  as  the  kidney,  etc.,  they  may  be 
the  seat  of  metastatic  deposit.  They  are  enlarged  in  acute  and 
chronic  forms  of  letiksemia  and  Hodgkin's  disease.  In  these  diseases 
the  spleen  and  liver  are  also  enlarged. 

Acute  Adenitis  (Acute  Lymphadenitis). — The  lymph-nodes  in 
infants  and  children  are  peculiarly  susceptible  to  acute  infections, 
which  are  for  the  most  part  pyogenic  (staphylococcic  and  strepto- 
coccic). Van  Arsdale  collected  500  cases  of  acute  lymphadenitis 
seen  by  him.  He  found  that  77  per  cent,  of  them  were  in  children. 
They  are  especially  liable  to  the  cervical  infections.  Eighty-five  per 
cent,  of  the  cases  in  children  were  infections  of  the  lymph-nodes  of 
the  neck,  the  frequency  in  adults  being  only  half  as  great. 

Etiology. — Most  of  the  infections  of  the  lymph-nodes  in  children 
are,  according  to  Van  Arsdale,  acute  (79  per  cent.).  The  majority 
of  them  are  pyogenic.  Children  are  subject  to  acute  infections  of 
the  scalp,  face,  mouth,  nose,  tonsils,  and  mucous  membrane  of  the 
nasopharynx.  The  lymph-nodes  draining  these  regions  are  in  the 
direct  line  of  infection.  Thus  eczema  and  skin  eruptions  of  all  kinds, 
stomatitis  of  all  varieties  and  inflammation  of  the  tonsils  and  the 
nasopharyngeal  space,  will  give  rise  to  enlargement  of  the  lymph- 
nodes.  If  the  infection  is  severe,  supjouration  occurs.  It  is  owing 
to  these  causes  and  to  the  breaches  of  surface  caused  by  slight  trauma- 
tism that  this  form  of  adenitis  is  so  common.  The  essential  exciting 
cause  of  acute  lymphadenitis  is  the  invasion  of  the  nodes  by  pyogenic 
bacteria  entering  through  the  lymph-channels. 

Symptoms. — The  s^Tiiptoms  of  lymphadenitis  in  infants  and  chil- 
dren are  essentially  the  same  as  in  the  adult  subject.  The  node  is  at 
first  felt  as  a  hard  nodular  mass  beneath  the  skin.  One  node  or  sev- 
eral may  be  infected.  There  is  always  some  fever.  At  first  the  skin 
over  the  node  is  of  normal  color,  but,  as  the  inflammation  progresses, 
it  becomes  involved,  red,  and  finally  there  develop  all  the  signs  of  an 
ordinary  abscess. 

Diagnosis. — The  diagnosis  is  not  difficult.  The  history  and  gen- 
eral course  at  once  point  to  the  nature  of  the  disease.     When  the 


DISEASES  OF  THE  LYMPH-NODES.  717 

region  about  the  parotid  is  affected,  it  is  at  times  difficult  to  tell 
whether  there  is  an  infectious  parotitis,  or  whether  the  nodes  just 
beneath  or  above  the  j)arotid  are  involved.  A  preauricular  gland 
situated  in  front  of  the  ear  on  the  parotid  gland  is  apt  to  enlarge  and 
suppurate.  The  nodes  underneath  the  angle  of  the  jaw  and  in  front 
of  the  border  of  the  mastoid  sometimes  enlarge  and  suppurate,  in- 
volving the  parotid  bj  collateral  swelling.  In  all  of  these  cases,  it  is 
important  to  remember  that  a  line  drawn  parallel  to  the  lower  border 
of  the  body  of  the  jaw  marks  off  the  parotid  above,  and  the  lymph- 
nodes  below.  In  exceptional  cases,  the  swelling  of  infectious  parotitis 
may  extend  lower  than  this  line. 

Treatment. — The  treatment  of  acute  lymphadenitis  is  at  first  abor- 
tive. Cold  applications  to  the  nodes  which  are  enlarged  and  access- 
ible, such  as  those  of  the  neck,  relieve  the  pain  and  in  many  cases 
lessen  the  severity  of  the  reaction.  This  result  is  frequently  seen  in 
cases  where  infection  of  the  nodes  of  the  neck  results  from  tonsillitis. 
Sometimes,  in  spite  of  all  that  can  be  done,  suppuration  occurs  as  a 
result  of  infection  of  cervical,  axillary  (vaccination),  and  inguinal 
nodes.  In  that  case,  the  affected  node  should  be  incised.  The  further 
treatment  of  such  cases  is  surgical. 

Chronic  Lymphadenitis. — Chronic  or  subacute  enlargement  of 
the  lymph-nodes  in  children  may  be  pyogenic,  tuberculous,  or  syphi- 
litic. Of  the  cases  collected  by  Van  Arsdale,  only  21  per  cent,  in 
infants  and  children  were  of  chronic  pyogenic  origin,  as  against  12 
per  cent,  in  the  adult.  On  the  other  hand,  only  6  per  cent,  of  all  the 
cases  of  adenitis  in  infants  and  children  were  tuberculous.  In  the 
adult,  the  tuberculous  forms  of  lymphadenitis  are  twice  as  frequent 
as  in  children.  It  is  thus  seen  that  even  in  chronic  enlargements  of 
the  lymph-nodes  of  infants  and  children  the  occurrence  of  tuberculous 
forms  gives  the  lowest  percentage. 

Symptoms. — The  symptoms  of  chronic  enlargement  of  the  lymph- 
nodes  in  infants  and  children  are  nodular  tumors  corresponding  to 
the  affected  lymph-nodes.  The  enlargement  may  be  single  or  mul- 
tiple. Sometimes  a  whole  packet  of  nodes  is  enlarged.  The  nodes 
most  commonly  enlarged  are  those  at  the  angle  of  the  jaw.  This 
occurs  in  infants  and  children  who  suffer  from  chronically  enlarged 
tonsils  and  adenoids.  As  a  rule  the  nodes  affected  remain  enlarged 
for  months.  At  times  they  are  somewhat  less  swollen.  They  do  not 
suppurate  unless  there  is  a  tendency  to  a  breaking-down  of  tissue. 
In  all  of  these  cases  there  is  not  only  toxic  irritation,  but  also  a  true 
hyperplasia  of  the  tissue  of  the  glands.  I  have  seen  these  nodes 
removed  and  opened.  Some  of  them  have  a  soft,  broken-down  centre 
resembling  that  of  the  tuberculous  nodes. 

Treatment. — The  treatment  of  chronic  lymphadenitis  is  directed 


718  LYMPH-NODES,  DUCTLESS  GLANDS  AND  BLOOD. 

toward  removing  the  source  of  infection.  If  the  tonsils  are  enlarged 
and  adenoids  are  present,  they  should  be  removed.  A  tonic  course 
of  treatment,  good  food,  out-of-door  exercise,  iron,  and  cod-liver  oil 
is  indicated.  In  spite  of  these  measures  manj^  cases  do  not  improve. 
If  the  enlargement  of  the  nodes  in  such  cases  is  localized,  the  question 
of  the  advisability  of  removing  them  arises.  That  measure  should 
not  be  resorted  to  unless  there  is  a  reasonable  certainty  that  they  are 
tuberculous,  and  when  all  other  treatment  has  failed. 

DISEASES  OF  THE  THYROID  GLAND. 

General  enlargement  of  the  thyroid  is  not  uncommon  in  infancy 
and  childhood.  iN^ormally  the  thyroid  gland,  and  especially  its  isth- 
mus, can  be  made  out  only  by  careful  palpation.  The  isthmus  is 
indicated  by  a  very  slightly  raised  structure  passing  across  the  trachea 
beneath  the  cricoid  cartilage.  The  lateral  lobes  cannot  be  palpated, 
except  in  cases  in  which  these  lobes  are  enlarged  or  where  there  are 
subsidiary  thyroid  masses.  In  endemic  cretinism  and  in  some  forms 
of  the  sporadic  type  of  cretinism  and  in  cases  of  dwarfs  in  goitre  dis- 
tricts, the  enlarged  lateral  or  supernumerary  lobes  beneath  and  just 
in  front  of  the  anterior  border  of  the  sternomastoid  muscle  can  be 
palpated.  Cystic  growths  of  the  thyroid  are  seen  in  front  of  the 
trachea,  generally  just  above  the  notch  of  the  sternum.  They  may 
occur  in  very  young  infants  or  in  children  of  four  or  five  years  of 
age.  Enlargement  of  the  isthmus  occurs  chiefly  in  girls  (Fig.  148). 
In  these  cases  there  is  a  disturbance  of  the  heart  functions  and  symi> 
toms  of  the  onset  of  morbus  Basedowii. 

Cretinism. — Cretinism  is  a  chronic  affection  which  is  character- 
ized by  a  defective  gi'owth  of  the  bones  of  the  skeleton  in  their  long 
axes,  accompanied  by  a  distinct  set  of  mental  symptoms  and  by 
changes  in  the  soft  parts.  There  are  two  forms,  the  endemic  and 
the  sporadic. 

Endemic  Cretinism. — Endemic  cretinism  occurs  in  certain  dis- 
tricts of  Continental  Europe.  It  does  not  exist  in  this  country 
(Osier).  The  pictures  presented  by  endemic  and  sporadic  cretinism 
are  similar.  According  to  the  recent  studies  of  Dolega,  His,  and 
Bernard,  their  pathologic  anatomy  is  also  similar.  Endemic  cre- 
tinism is  an  advanced  stage  of  a  degeneration  beginning  with  goitre 
manifestations.  The  resulting  changes  are  due  to  "athyreosis,"  a 
suspension  or  disturbance  of  the  functions  of  the  thyroid  gland. 
Sporadic  cretinism,  although  also  due  to  athyreosis,  occurs  without 
goitre.  The  peculiar  formation  of  the  skull  in  cretinism,  endemic  or 
sporadic,  is  now  known  not  to  be  due  to  a  premature  synostosis  of  the 
OS  basilare  and  the  sphenoid,  as  was  at  first  thought  by  Virchow.     The 


DISEASES  OF  THE  TH¥EOID  GLAND. 


719 


brachycephalic  skull  as  manifested  in  a  broadening  of  the  bridge  of 
the  nose,  and  the  prognathous  expression  are  due  to  a  deficient  growth 
of  the  bones  at  the  base  of  the  skull,  in  their  long  axes.  The  sutures 
and  fontanelles  remain  open  for  a  long  time.  Dentition  is  delayed. 
The  skin  is  myxoedematous  in  sporadic  cretinism  only.  Dwarfism 
and  anaemia  are  common  to  both  forms. 

Fig.  163. 


.  / 


Enlarged  thyroid  in  a  cliild. 


Sporadic   Cretinism. — Occurrence. — The    disease   may   appear  in 

utero  or  at  any  time  after  birth.     Fully  one-half  of  the  cases  develop 
before  the  eighteenth  month  (Fletcher  Beach). 

Symptoms.- — I  have  published  cases  in  which  the  symptoms  were 
evident  within  a  month  or  five  weeks  after  birth.  The  history  was 
as  follows :  In  one  case  there  was  another  cretin  in  the  family ;  in 
the  others  there  was  no  such  history.  The  birth  as  a  rule  was  nor- 
mal (Fig.  149).  The  infant  was  jaundiced,  but  fairly  well  nour- 
ished. It  lay  in  a  torpid  state  and  was  only  roused  when  severely 
teased.     The  infant  was  easily  chilled.     The  cry  was  deep  and  coarse. 


■20 


LYMPH-NODES,  DUCTLESS  GLANDS  AND  BLOOD. 


The  foretead  was  low  and  narrow.  The  eyelids  were  puffy.  The- 
tongue  was  large,  broad,  and  thick,  at  times  protruding  from  the 
mouth.  The  abdomen  was  large,  and  the  thighs  and  legs  were  out 
of  proportion  to  the  length  of  the  trunk.  The  skin  had  a  greenish 
hue.  The  thyroid  gland  could  not  be  found.  The  surface  was  cool 
and  the  rectal  temperature  97°  or  97.8°  F.  (36.1°-36.5°  C).  The 
blood  in  these  early  cases  has  foetal  characteristics.     There  isnoleuco- 

FiG.  164. 


Congenital  sporadic  cretinism.     Infant,  four  weelis  old. 


cytosis.  In  the  cases  which  develop  some  months  after  birth  the 
infant  may  at  first  be  bright  and  normal.  Six  to  nine  months  after 
birth  it  may  have  had  some  slight  illness,  such  as  an  adenitis,  and 
after  this  the  change  was  noticed,  or  the  change  may  have  occurred 
without  any  preceding  illness.  The  infant  ceases  to  notice  objects 
about  it,  and  becomes  stupid  and  weaker.  It  may  previously  have 
attempted  to  walk  or  stand,  but  ceases  to  make  an  effort  to  do  so 
(Plate  XXXI.).  The  child's  expression  is  idiotic.  It  has  a  mean- 
ingless smile  most  of  the  time  and  does  not  play.  The  skin  has  a 
wi-inkled  and  myxoBdematous  appearance,  the  color  being  not  only 
pale,  but  also  greenish.  The  nose  is  flattened,  the  lips  are  thickened, 
and  the  hair  becomes  dry  and  sparse.     The  forehead  is  narrow  and 


PLATE   XXXI 


.'^S^  ^--^S^rv        j4 


"N. 


^^,  ^.. ,.., 


sporadic  Cretinism.      Child  fifteen  monthis  of  age- 


DISEASES  OF  THE  TH¥EOID  GLAND. 


721 


the  face  has  a  prognathous  expression — "  monkey-like,"  as  one  mother 
expressed  it.  There  are  no  teeth.  The  neck  is  short  and  thick. 
The  genitals  are  large  for  the  age.     The  skin  of  the  scrotum  is  thick- 


FiG.  165. 


Sporadic  cretinism  ;  myxoedema  marked.     Child,  twenty  months  of  age. 


ened.     The  anaemia  in  these  cases  is  extreme.     The  haemoglobin  may 
be  as  low  as  18  per  cent.     The  leucocytes  may  be  as  high  as  18,000, 
and  the  red  blood-cells  5,600,000. 
46 


722 


LYMPE-NODES,  DUCTLESS  GLANDS  AND  BLOOD. 


In  other  cases,  the  symptoms  are  at  first  more  of  the  myxoede- 
matous  type.  The  skin,  especially  that  of  the  face,  has  a  greenish- 
yellow,  waxy,  puffy  appearance.  The  npper  and  lower  eye-lids  are 
swollen,  as  in  nephritis.  With  these  appearances,  there  are  the  dry 
hair,  the  macrogiossia,  the  guttural  voice,  the  dwarfish  appearance, 
the  protuberant  abdomen,  and  the  mental  dulness.  The  expression 
of  the  face  is  less  prognathous  than  in  the  first  form.  In  one  of  my 
cases  the  infant  was  in  good  health  until  the  sixteenth  month.  It 
then  developed  abscesses  over  the  body,  after  which  the  symptoms  of 
cretinism  were  noticed.     The  abscesses  were  peculiar,  the  granula- 


Fig. 

166. 

^^^^^^^^^^J 

^P^ 

9^1 

^^^^^^  -^ 

S 

.      ^ 

hh 

■     "^  J 

? 

"''k9^^| 

ifl 

^m    -^yar^ 

M 

^m 

1 

■  J 

s 

'^^^^ 

Cast  of  the  hand  of  a  boy  cretin,  four  years  of  age.     Flat  and  spade-like  in  form  ; 
shows  also  the  thickened  and  hypertrophied  hypothenar  eminence. 


tions  sluggish,  and  the  pus  was  creamy.  The  skin  was  not  (Edema- 
tous, but  myxccdematous. 

In  both  forms  the  hands  are  large,  flat,  and  spade-like.  The 
hypothenar  eminence  is  thick,  square,  and  hypertrophied,  as  in  the 
lower  animals  (Koplik  and  Lichtenstein)  (Fig.  1G6).  In  some  cases 
the  thyroid  gland  cannot  be  felt,  in  others  it  is  small,  and  in  excep- 
tional cases  there  is  goitre  (7  cases  of  Osier's  scries).  In  some  cases, 
supraclavicular  masses  of  fat  or  fatty  tumors  behind  the  sternomastoid 
muscles  are  apparent.  I  have  seen  these  masses  of  fat  in  cases  which 
had  suffered  a  return  of  symptoms  after  suspension  of  treatment. 

Etiology. — The  etiology  of  sporadic  cretinism  is  as  yet  absolutely 
unknown.  Experimental  and  operative  pathology  have  demonstrated 
that  interference  with  the  function  of  the  thyroid  gland  (athyreosis) 
will  produce  a  condition  (myxoedcma)  closely  resembling  cretinism 


DISEASES  OF  THE  THYROID  GLAND. 


723 


(Horsely,  Reverdin,  Koclier).  The  essential  cause  of  endemic  cret- 
inism is  thought  to  be  some  form  of  infection  (Fagge).  Sporadic 
cretinism  is  also  ranked  by  some  authors  among  the  infections. 

Morbid  Anatomy. — There  are  cases  of  sporadic  cretinism  in  which 
the  thyroid  gland  is  absent.  It  has  not  developed  in  fcetal  life  and 
is  not  found  at  autopsy.  In  other  cases  there  is  found  at  autopsy 
a  small  atrophied  gland  which  is  sclerosed  and  much  reduced  in  size. 
Such  cases  have  been  published  as  following  the  infectious  diseases. 

Fig.  167. 


Cretin,  myxcedematous  type,  4  years  of  age. 


Lastly,  there  are  cases  with  goitre.  The  changes  in  the  thyroid,  when 
it  is  found  in  sporadic  cretinism,  have  been  described  by  Barker. 
There  is  an  increase  of  connective  tissue.  The  parenchyma  is  re- 
placed by  small  and  large  irregularly  shaped  cells,  which  are  granular 
and  unlike  the  normal  tissue.  Some  of  the  acini  are  almost  solid ; 
others  are  cystic  and  filled  with  colloid  material.  The  cells  may  con- 
tain vacuoles ;  their  nuclei  may  show  "  karyorrhexis."     The  nuclear 


724  LYMPE-NODES,  DUCTLESS  GLANDS  AND  BLOOD. 

changes  are  characteristic  of  degenerative  processes.  Some  of  the 
acini  are  replaced  by  connective  tissue. 

The  Bones. — In  the  recent  v^ork  of  His,  Dolega,  and  Bernard,  it 
has  been  clearly  shown  that  ossification  in  the  pre-existent  cartilagi- 
nous structures  of  the  skeleton  is  delayed  in  all  its  phases.  This  is 
evinced  in  the  delayed  appearance  of  ossification  centres,  the  delayed 
bony  transformation  of  the  epiphyses,  and  in  the  persistence  of  the 
epiphyseal  zones.  In  some  cretins,  ossification  is  completed  at  a  very 
late  period  of  life;  in  others,  infantile  conditions  are  perpetuated. 
The  dwarfing  of,  the  whole  skeleton  is  thus  explained,  not  by  a  pre- 
mature synostosis,  but  by  faulty  proliferation  and  ossification  of  the 
epiphyseal  cartilages.  The  bones  of  the  skull  are  affected  in  the 
same  manner  as  the  vertebrae  and  the  long  bones,  in  that  they  fail 
to  grow  in  their  long  diameters  and  in  that  ossification  centres 
appear  late. 

Diagnosis. — The  diagnosis  is  not  difficult  in  advanced  cases.  The 
early  cases  require  close  study.  In  these,  the  stupidity  increasing  to 
absolute  idiocy,  the  retarded  growth,  the  change  in  the  expression,  the 
swollen  eyelids,  thick  lips,  dry  hair,  wrinkled  myxoedematous  skin, 
the  flat,  spade-like  hands,  the  dwarfish  appearance,  and  the  reduced 
internal  temperature,  all  point  to  the  diagnosis.  In  later  eases,  the 
extreme  anaemia,  myxoedema,  and  pronounced  prognathous  expression 
of  the  face  are  apparent. 

Differential  Diagnosis. — Mongolian  Idiocy. — This  is  a  form  of 
genetous  idiocy  with  which  cretinism  is  frequently  confounded.  The 
idiots  resemble  cretins.  The  growth  is  stunted.  The  mouth  is  kept 
open.  The  facies  seen  in  cases  of  adenoids  is  present  but  due  in  these 
cases  to  peculiar  bone  formations  at  the  base  of  the  skull.  The  tongue 
is  large  and  fissured ;  the  papillas  of  the  tongue  are  enlarged  and  erect. 
The  tongue  protrudes  from  the  mouth  (Plate  XXXII.)  ;  the  lips  are 
thick;  the  voice  is  coarse  and  guttural.  The  temperature  may  be 
subnormal,  but  is  generally  normal.  The  skin  is  dry  and  the  hair 
coarse.  In  young  infants  the  skin  may  be  delicate.  The  patients  are 
easily  chilled.  The  musculature  is  flabby.  The  infants  cannot  hold 
the  head  erect.  The  occiput  is  flattened,  the  neck  short  and  thick. 
There  is  strabismus,  and  the  axes  of  the  eyelids  have  a  Mongolian 
slant — that  is  to  say,  they  converge.  The  inner  eyelid  comes  down 
toward  the  nose  with  a  rapid  slope.  The  bridge  of  the  nose  is  flat. 
The  head  is  small  and  obtusely  rounded;  the  antero-posterior  diam- 
eter is  nearly  equal  to  the  lateral  one.  The  fontanelles  remain  open 
late.  The  skin,  however,  is  not  myxoedematous,  nor  is  the  expression 
prognathous  as  in  the  cretin.  The  ana?mia  is  as  a  rule  marked;  in 
some  cases  the  skin  has  a  greenish  hue.  There  is  a  curving  inward 
of  the  tip  of  the  little  finger.     The  second  phalanx  is  short  and  the 


PLATE  XXXII 


Mongolian  Types  of  Idiocy.     Infant  and  young  children. 


DISEASES  OF  THE  THYROID  GLAND.  725 

terminal  phalanx  displaced.  West  has  shown  that  although  this 
deformity  is  very  common  in  these  idiots,  it  is  not  pathognomonic  of 
Mongolian  idiocy.  Many  of  the  subjects  of  this  form  of  idiocy  grow 
to  adult  life  and  have  varying  degrees  of  intelligence. 

The  Dwarf  with  Idiocy. — There  may  be  several  of  these  dwarfs 
in  a  family.  The  thyroid  gland  is  enlarged  at  the  beginning  or 
during  the  course  of  the  condition.  The  mental  state  is  much  stunted. 
The  general  growth  of  the  body  is  retarded.  Dwarfs  are,  however, 
well  formed.  The  hands  and  extremities  are  perfect  and  the  skin  is 
not  as  a  rule  myxoedematous. 

Infmitilism. — Infantilism  combined  with  lipomatosis  may  be  con- 
founded with  cretinism.  In  this  form  of  disease  there  is  no  myx- 
edema and  the  skin  is  very  delicate  and  soft.  The  genitals  are 
atrophied.  The  expression  of  the  face  is  that  of  child-like  simplicity, 
the  forehead  is  low  and  narrow.  The  hair  is  dry,  and  does  not  grow ; 
the  finger-nails  do  not  grow.  There  may  be,  as  in  the  case  I  pub- 
lished, blindness.     The  mental  state  is  one  of  mild  idiocy. 

Treatment. — The  treatment  of  cretinism  constitutes  one  of  the  mar- 
vellous chapters  of  modern  medicine  developed  by  experimental  path- 
ology. The  administration  of  thyroid  extract  results  in  a  partial 
restoration  of  the  mental  capacity  and  a  return  to  growth  and  develop- 
ment approaching  the  normal.  The  writer  published  in  1897  some 
cases  of  cretinism  diagnosed  early  in  infancy,  in  which  the  treatment 
was  begun  at  once.  In  those  in  which  the  treatment  was  begun  at 
the  age  of  one  month,  the  children  have  become  bright  and  apparently 
normal.  In  those  in  which  it  was  inaugurated  at  the  fifteenth  month, 
the  children  have,  after  five  years  of  treatment,  remained  somewhat 
backward  in  mental  development.  One  patient,  now  a  boy  of  six 
years,  goes  to  school,  and  recites  his  alphabet,  but  is  very  simple  in 
manner.  In  these  late  cases  the  treatment  does  not  give  the  complete 
results  at  first  expected. 

Treatment  is  begun  by  the  administration  of  the  dried  extract  of 
thyroids  of  sheep,  grain  |-  (0.03)  t.  i.  d.,  and  increase  the  dose  until 
the  infant  takes  grain  j  (0.06)  three  times  daily.  After  the  symp- 
toms have  retrograded,  the  dosage  is  kept  stationary  for  a  few  months. 
It  is  then  reduced  or  the  remedy  is  given  only  every  other  day.  If 
symptoms,  such  as  stupidity,  pallor,  or  reduced  temperature  reappear, 
the  dose  is  increased.  The  first  sign  of  improvement  is  a  reduction 
of  the  anaemia,  as  evidenced  in  the  increase  of  hsemoglobin.  The 
body  temperature  rises  to  the  normal.  The  skin  becomes  of  normal 
delicacy  and  supple.  The  stature  increases  and  the  hair  becomes 
glossy.  Thomson,  of  Edinburgh,  has  published  cases  of  adult  cretins 
whose  bones  became  softened  after  the  prolonged  administration  of 
thyroids.     These  were  cases  in  which  treatment  was  begun  late  in 


726 


LYMPH-NODES,  DUCTLESS  GLANDS  AND  BLOOD. 


life.  The  symptoms  of  excessive  administration  of  thyroids  include 
rise  of  temperature  and  slight  diarrhoea,  due  to  toxins  in  the  thyroids. 
I  have  found  thyroid  therapy  of  doubtful  utility  in  cases  of  Mon- 
golian idiocy.  In  the  dwarfs  above  mentioned,  it  causes  increase  of 
stature ;  the  intelligence,  hovs^ever,  remains  backward. 

Fig.  168. 


Infantilism  and  lipomatosis  universalis  in  a  boy  ten  years  of  age. 


Dwarfism;  Nanism. — A  dwarf  is  a  person  of  very  small  stature. 
The  tallest  dwarf  according  to  Sainton  should  not  exceed  1.5  metres 
or  59  inches  in  height. 

Differentiation  from  Infantilism. — Infantilism  is  frequently  con- 
founded with  dwarfism,  but  it  is  the  direct  opposite  of  the  latter  con- 


DISEASES  OF  TEE  THYEOID  GLAND.  727 

dition.  Meige  defines  infantilism  as  a  physical  and  mental  condition 
found  in  individuals  whose  sexual  apparatus  is  congenitallj  or  acci- 
dentally in  a  state  of  arrested  development.  Infantilism  is  charac- 
terized by  rounded  face,  dimpled  features,  gracile  limbs,  prominent 
lips,  smooth  skin,  fine,  clear  complexion,  delicate  hair,  slightly  marked 
eyelashes  and  eyebrows,  small  nose,  long  torso,  prominent  abdomen, 
and  a  rounded  obese  conformity  of  the  body  (Fig.  168).  There  is 
an  absence  of  hair  on  the  pubes  and  axillae,  the  mental  state  is  that 
of  childhood  and  the  stature  is  not  that  of  a  dwarf.  They  are  not 
vicious,  though  at  times  moved  to  anger.  An  excellent  example  and 
portrait  of  this  condition  is  given  elsewhere. 

Dwarfism,  on  the  other  hand,  is  an  arrest  of  development.  The 
mental  state  varies ;  at  times  dwarfs  are  quite  clever. 

Varieties. — Sainton  describes  dwarfs  as: 

1.  Myxcedematous  dwarfs.  2.  Achondroplasic  dwarfs.  3.  Rachitic 
dwarfs.  4.  Spondylitic  dwarfs.  5.  Anangioplastic  dwarfs.  6. 
Pygmies  and  dwarfs  with  lesions  of  the  suprarenal  capsules. 

1.  The  myxcedematous  dwarfs  are  quite  numerous,  the  head  is 
large,  the  face  puffy,  complexion  yellow,  skin  thick,  the  genitals 
atrophic,  the  thyroid  absent  of  scarcely  perceptible,  and  the  voice 
thin  and  high-pitched.  The  thyroid  and  glands  supplying  internal 
secretions  are  in  a  state  of  atrophy.  Thus  there  is  an  etiological 
factor  in  this  atrophy.  The  mental  condition  is  not  as  bright  as  in 
other  forms  of  dwarfism. 

2.  The  achondroplastic  dwarfs  are  elsewhere  described.  They 
are  brighter  than  the  above  class.  Their  characteristics  have  been 
described  by  Pierre  Marie.  The  arrest  of  development  is  most  appar- 
ent in  the  lower  extremities,  the  trunk  and  arms  being  almost  normal. 
Micromelia  is  a  term  at  times  applied  to  this  condition. 

3  and  4.  Spondylitic  and  rachitic  dwarfs  are  not  as  frequent. 
The  former  condition  depends  on  a  curvature  of  the  spine  and  a 
rigidity  of  the  cervical  vertebrse. 

5.  Anangioplastic  dwarfs  are  most  uncommon.  They  are  per- 
fectly formed,  small,  graceful  individuals.  I  have  seen  several  ex- 
amples of  this  type  and  have  described  them. 

6.  Pygmies  described  by  Poncet  and  Levair  as  having  an  absence 
of  physical  abnormalities,  bodies  are  small  but  harmoniously  devel- 
oped ;  such  are  the  dwarfs  of  the  Eskimos,  Laplanders,  Fuegians,  and 
Central  Africa. 

Dwarfism  is  therefore  a  condition  of  mal-development  dependent 
in  many  cases  on  mal-nutrition  or  a  lack  of  the  internal  secretions. 


728  LTMPH-NODES,  DUCTLESS  GLANDS  AND  BLOOD. 

DISEASES  OF  THE  THYMUS  GLAND. 

Landmarks, — The  tlivmiis  is  a  glandular  organ  enclosed  in  a  cap- 
sule. It  is  situated  in  the  anterior  mediastinum,  and  contains  in  its 
structures  a  white  tenacious  fluid  substance  which  is  present  in  vary- 
ing quantities.  Sappey  shows  that  the  thymus  in  the  newhorn  infant 
extends  from  the  upper  edge  of  the  manubrium  sterni,  5  cm.  down- 
ward. Its  upper  border  may  reach  the  isthmus  of  the  thyroid  or  may 
be  removed  2-|  cm.  from  it.  It  extends  downward  to  the  middle  or 
upper  third  of  the  pericardium.  In  exceptional  cases  it  may  have  a 
longitudinal  diameter  of  11-|  cm.,  reaching  the  diaphrag-m  (Triese- 
thau).  The  thymus  is  about  2  to  3  cm.  wide.  Luschka  makes  it 
unsymmetrical,  consisting  of  two  lobes  united  by  an  isthmus.  It  lies 
over  the  course  of  the  pulmonary  artery  and  is  surrounded  by  a  reflec- 
tion of  the  pericardium.  It  is  separated  from  the  sternum  by  loose 
connective  tissue.  Its  length  varies  from  4  cm,  in  the  nursling,  to 
11  cm.  in  the  ninth  year,  the  average  ratio  to  the  body  length  being 
1  to  7  or  8. 

Weight. — Its  weight  varies.  In  the  results  which  the  writer 
obtained  in  collaboration  with  Jacobi,  it  did  so  within  wide  limits. 
In  infancy  the  average  weight  is  20  grammes ;  from  the  second  to  the 
fourteenth  year  it  is  24  gTammes.  After  the  twenty-fifth  year  the 
thymus  atrophies  and  may  weigh  2.2  gTammes  (Friedeleben).  In 
abnormal  states  the  weight  may  be  32  grammes  (Triesethau,  Pott ). 
The  causes  of  the  enlargement  of  the  gland  and  the  conditions  under 
which  it  occurs  are  not  as  yet  known.  The  gland  is  large  in  infants 
dying  of  the  most  diverse  diseases. 

Percussion." — Under  the  most  favorable  conditions  it  is  difficult 
to  ascertain  the  exact  size.  Tiie  thymus  has  sometimes  been  marked 
out  as  large  during  life,  and  post  mortem  found  to  be  small.  As  a 
rule,  an  area  of  dulness  situated  behind  the  upper  part  of  the  sternum, 
and  discernible  on  gentle  percussion,  may  be  cautiously  interpreted 
as  due  to  the  thymus  (Sahli).  An  unsymmetrical  area  giving  dul- 
ness on  one  side  of  the  sternum  is  probably  due  to  the  thymus 
(Luschka),  especially  in  subjects  under  the  second  year.  The  thymus 
may  be  seen  by  rc-ray  as  a  shadow  behind  the  upper  sternal  region. 

Abnormal  Conditions. — Xone  of  the  abnormal  conditions  of  the 
thymus  can  be  diagnosfd  with  certainty  during  life. 

Hypertrophy  of  the  Thymus  Gland,  Including  So-called  ' '  Thymus 
Death." — Simple  hypertrophy  of  the  thymus  gland,  irrespective  of 
its  presence  as  a  cause  of  sudden  death,  has  been  observed  by  Virchow, 
Grawitz,  Jacobi,  and  others.  It  may  exist  without  causing  any 
symptoms,  and  only  be  discovered  postmortem  in  children  who  have 
died  of  various  diseases.  In  other  cases  an  enlarged  or  hypertrophied 
thymus  has  been  described  as  causing  a  series  of  symptoms  similar 


DISEASES  OF  THE  THYMUS  GLAND.  729 

to  what  is  seen  in  tlie  adult  subject  in  forms  of  asthma.  Virchow, 
Grawitz,  West,  and  Goodhardt  have  described  such  cases  under  the 
head  of  "  Thymic  Asthma."  These  cases  are  attended  with  par- 
oxysms resembling  those  of  laryngismus  stridulus  with  difficult 
breathing.  Some  of  the  cases  described  by  the  above  authorities  have 
eventuated  in  convulsions  and  sudden  death.  Recently  Hochsinger 
has  attempted  to  revive  the  term  "  thymic  asthma  "  as  applying  to 
cases  of  laryngeal  stridor ;  the  symptom-complex  in  such  cases  being 
due,  in  his  opinion,  to  an  enlarged  condition  of  the  thymus. 

There  has  been  much  discussion  as  to  the  existence  of  such  an 
entity  as  "  thymic  asthma." 

There  is  another  form  of  sudden  death,  the  so-called  ''  thymus 
death,"  which  has  been  ascribed  to  hypertrophy  of  the  thymus  gland. 
These  cases  have  been  described  by  Virchow,  Grawitz,  Pott,  and 
others,  and  there  seems  to  be  a  tendency  in  some  quarters  to  attribute 
certain  cases  of  sudden  death  to  the  existence  of  an  enlarged  thymus. 
In  one  case,  described  by  Pott,  the  thymus  weighed  32  grammes,  was 
9  cm.  long  and  1^  cm.  thick.  Cases  of  thymus  death  have  been 
described,  for  the  most  part,  in  children  who  are  the  victims  of  a 
condition  known  as  status  lymphaticus.  This  condition  should  be 
differentiated  from  that  described  under  the  heading  of  Scrofulosis, 
and  for  the  sake  of  clearness  will  be  described  under  the  head  of 
Status  Lymphaticus  combined  with  that  of  thymus  death. 

In  the  work  of  Jacobi  it  was  shown  that  hemorrhages  of  the 
thymus  are  not  uncommon,  and  are  present  in  a  number  of  conditions, 
especially  in  pertussis.  Inflammation  of  the  thymus  may  be  present 
in  inflammatory  conditions  of  the  pleura  and  pericardium.  Steu- 
dener  has  published  a  case  of  sarcoma  of  the  thymus,  and  Vogel  one 
of  carcinoma  of  that  organ,  occurring  in  childhood.  Demme  pub- 
lished a  case  of  isolated  tuberculosis  of  the  thymus.  In  the  mono- 
graph of  Jacobi,  general  tuberculous  infection  of  the  thymus  was 
investigated,  as  was  also  the  condition  as  found  in  diphtheria.  In 
the  latter  disease  necrobiosis  of  the  thymus  was  found  as  described 
by  Oertel  in  other  organs.  Congenital  syphilis  may  manifest  itself 
in  arterial  and  connective-tissue  changes.  Abscess  of  the  thymus 
is  rare. 

Status  Lymphaticus  (Lymphatis'm;  Lymphatic  Constitution).- — - 
This  condition  is  found  chiefly  in  children  who  are  subjects  of  rachitis 
and  are  moderately  well  nourished  but  angemic.  They  have  enlarged 
lymph-nodes  at  the  angle  of  the  jaw,  in  the  axilla,  and  in  the  groin, 
and  may  have  attacks  of  laryngismus  stridulus.  They  have  enlarged 
tonsils,  adenoid  tissue  in  the  posterior  nares,  and  enlargement  of  the 
adenoid  tissue  at  the  base  of  the  tongue.  On  the  other  hand,  they 
present  none  of  the  skin-,  bone-,  and  joint-affections  seen  in  the  scrof- 


730  LYMPH-NODES,  DUCTLESS  GLANDS  AND  BLOOD. 

ulous  or  tuberciiloiis  subject.  Escherich  has  published  cases  in  which 
there  were  30  attacks  of  larrugospasm  a  day.  The  patients  also  have 
symptoms  of  increased  excitability  of  the  peripheral  motor  nerves, 
such  as  Trousseau's  phenomena  and  Chvostek's  symptom.  I  have 
had  one  case  in  which  there  was  an  attack  of  laryngismus  at  every 
crying-spell.  The  patients  are  in  constant  danger  of  sudden  death. 
The  reader  is  referred  to  the  article  on  tetany  for  a  further  discussion 
of  these  cases.  In  rare  case5  in  which  sudden  death  has  occurred  an 
enlarged  thymus  has  been  found,  and  other  lesions  which  will  now 
be  described  under  the  title  of  Thymus  Death. 

Thymus  Death. — There  are  two  distinct  sets  of  cases  of  sudden 
death  in  which  the  thymus  has  been  found  to  be  enlarged.  The  first 
are  those  in  which,  postmortem,  absolutely  no  other  change  has  been 
found  than  the  presence  of  an  enlarged  thymus.  In  these  cases  the 
viscera  were  said  to  be  absolutely  normal,  but,  as  has  been  stated  else- 
where, there  were  evidences  of  lymphatism,  such  as  enlarged  tonsils, 
lymph-nodes,  and  solitary  follicles  in  the  intestine. 

The  second  set  of  cases  is  that  in  which  the  thymus  was  found 
not  only  to  be  enlarged,  but  apparently  pressing  on  the  trachea  or 
arch  of  the  aorta,  causing  complete  obliteration  of  these  organs.  The 
latter  set  of  cases  were  recorded  by  Beneke,  Lange,  and  Weigert. 
But  few  of  these  cases  published  are  to  be  considered  in  the  category 
of  thymus  death,  for  these  rather  represent  pathological  growths  of 
the  thymus  similar  to  any  other  tumor  which  might  lead  to  pressure 
effects.  Such  a  condition  of  the  thymus  is  exceedingly  rare.  What 
interests  the  physician  most,  especially  as  the  cause  of  sudden  death, 
are  the  cases  of  enlarged  thymus  in  which,  as  in  the  first  set,  no  signs 
of  pressure  were  found,  either  on  the  large  vessels  or  the  bronchi. 
That  death  in  these  cases  is  not  caused  by  pressure  is  now  generally 
conceded. 

The  theory  advanced  by  Paltauf  and  Escherich  is  not  unreserv- 
edly accepted  by  all.  Paltauf  contends  that  the  sudden  death  is  due 
to  an  anomalous  lymphato-chlorotic  constitution,  the  enlarged  thymus 
thus  being  only  one  of  the  manifestations  of  a  general  disturbance  of 
nutrition,  in  which  we  also  find  enlarged  lymph-nodes  and  tonsils,  and 
hyperplasia  of  lymphatic  tissue.  Under  the  influence  of  this  condi- 
tion there  are  changes  in  the  nerve-centres  of  the  heart,  as  a  conse- 
quence of  which  the  least  excitement  may  result  in  fatal  paralysis. 
Escherich,  in  addition,  while  accepting  this  theory,  thinks  that  in  the 
condition  of  lymphatism  there  is  an  auto-intoxication  whereby  the 
nervous  system  is  in  a  state  of  morbid  irritability  and  instability 
which  results  in  heart-syncope.  In  this  condition  the  functions  of 
the  thymus  are  probably  disturbed,  much  like  that  of  the  thyroid  in 
myxoedema  or  Basedow's  disease. 


DISEASES  OF  THE  THYMUS  GLAND.  731 

On  the  other  hand,  Richter  has  analyzed  all  the  cases  published 
of  the  so-called  thymus  death.  In  most  of  these  cases  there  were 
present  anatomically  other  conditions,  such  as  bronchitis,  intestinal 
catarrh,  or  some  other  disease,  to  account  for  the  fatal  issue.  In 
most  children  overtaken  by  this  form  of  death  there  is  a  condition  of 
lymphatism,  and  this,  in  addition  to  the  growing  thymus,  which  at 
the  age  of  two  years  is  quite  large,  has  been  made  accountable  for  the 
death  of  these  infants  and  children,  whereas  close  study  will  always 
reveal  some  other  morbid  condition  fully  equal  to  causing  this  issue. 
Thymus  death  is  one  of  the  rarer  forms  of  sudden  death  in  early 
infancy,  as  compared  with  other  forms.  I  have  seen  it  twice,  and 
know  of  nothing  more  distressing  than  such  an  occurrence.  The 
physician  may  be  examining  such  a  child  for  a  slight  movement,  when 
suddenly  the  infant  throws  the  head  backward,  there  is  a  noiseless  or 
snappy  inspiration,  the  eyes  turn  upward  and  sideways,  the  pupils 
dilate,  there  is  cyanosis  both  of  the  face  and  tongue  as  the  latter  be- 
comes swollen  and  caught  in  the  jaw;  there  is  a  convulsive  contrac- 
tion of  the  body  backward.  There  are  several  inefficient,  noiseless, 
shallow  inspiratory  movements,  the  body  then  relaxes,  the  face  be- 
comes ashy  pale,  and  the  infant,  within  one  or  two  minutes,  is  dead. 
The  heart  ceases  to  beat  at  the  beginning  of  the  attack.  It  is  really 
a  syncopal  death.  Escherich  has  recently  grouped  these  cases  under 
the  category  of  tetany  or  latent  tetany. 

There  is  another  form  of  death  in  lymphatic  infants  and  children 
which  occurs  in  chloroform  narcosis.  In  such  cases  the  heart  may 
suddenly  cease  to  beat  during  the  narcosis ;  or,  as  in  one  of  my  cases, 
the  child  may  have  withstood  the  narcosis,  though  it  was  noticed  to 
have  taken  the  chloroform  badly.  Twelve  hours  after  the  operation 
— ^which  in  this  case  was  one  of  appendicitis — the  temperature  rose 
slightly,  there  was  a  rapid  increase  in  the  heart  action,  the  pulse 
mounting  in  a  short  time  so  that  it  could  no  longer  be  counted ;  while 
the  heart  beat  at  the  rate  of  over  200  a  minute  (cardiac  paralysis),, 
the  pulse  could  not  be  felt  at  the  wrist.  Death  occurred  with  all  the 
signs  of  paralysis  of  the  cardiac  ganglia. 

In  the  case  last  described  the  child  was  extremely  lymphatic,  had 
a  thymus  enlarged  to  percussion,  and  a  year  previous  had  been  oper- 
ated on  for  adenoid  vegetations  and  enlarged  tonsils.  The  lymphatic 
nodes  throughout  the  whole  body  were  enlarged.  The  appendicitis 
from  which  the  child  suffered  was  one  of  the  mild  catarrhal  type. 
There  was  no  septic  peritonitis. 

Treatment. — Inasmuch  as  death  supervenes  in  these  cases  before 
anything  can  be  done  in  an  orderly  way,  it  is  almost  superfluous  to 
speak  of  treatment.  Pott,  however,  and  others  have  performed 
tracheotomy  in  these  cases  with  a  view  not  only  of  relieving  the 


732  LYMPH-NODES,  DUCTLESS  GLANDS  AND  BLOOD. 

spasm  of  the  glottis,  wliieli  in  some  instances  is  present,  but  of  per- 
forming artificial  respiration.  Others  have  intubated.  In  those  cases 
in  which  the  heart  has  ceased  to  beat,  we  can  scarcely  expect  to  revive 
its  action.  In  one  case  of  my  own  of  a  lymphatic  child  in  which  the 
heart  failed  at  the  outset  of  the  chloroform  narcosis,  became  irregular, 
and  threatened  to  stop  beating,  artificial  respiration,  the  Laborde 
method  of  resuscitation,  and  massage  over  the  cardiac  area  according 
to  the  method  described  by  Maas,  brought  the  child  to  life  again. 
We  will  not  always  succeed  in  this  manner. 

The  treatment  of  the  general  condition — the  status  lymphaticus — 
consists  in  the  removal  of  the  enlarged  tonsils  and  adenoids.  In 
these  cases  the  condition  of  the  lymphatic-node  enlargements  is  vastly 
improved  by  the  operation.  Good  food,  cod-liver  oil,  and  the  prepa- 
rations of  the  iodide  of  iron  are  also  indicated. 

Morse  has  recently  suggested  in  cases  of  laryngismus  with  attacks 
of  dyspnoea,  the  removal  of  the  thymus  if  the  organ  was  enlarged. 
Two  cases  thus  treated  were  relieved  temporarily,  but  the  symptoms 
ultimately  returned  and  the  patients  died. 

DISEASES  OF  THE  SPLEEN. 

Anatomical. — At  different  periods  of  childhood  the  length  of  the 
spleen  varies  from  4  to  10  cm.,  the  breadth  from  2  to  5  cm.,  the  aver- 
age thickness  being  about  0.5  cm.  It  forms  an  oval-shaped  body, 
behind  the  ninth,  tenth,  and  eleventh  ribs,  the  long  axis  running  in 
the  direction  of  the  ribs.  Up  to  the  second  month  of  life,  the  anterior 
edge  of  the  spleen  is  found  in  the  midaxillary  line ;  after  that,  it  may 
be  found  further  forward  than  this  line,  or  posteriorly  to  it.  The 
upper  edge  corresponds  to  the  upper  edge  of  the  ninth  rib ;  the  lower 
border  to  the  lower  border  of  the  eleventh  rib.  The  spleen  may  be 
located  by  percussion  and  palpation. 

Percussion. — The  patient  is  caused  to  lie  on  the  back.  It  is  not 
necessary  to  cause  children  to  lie  in  an  inclined  lateral  posture.  The 
upper  border  is  first  located  by  percussing  from  above  downward  in 
the  midaxillary  line  on  the  left  side.  At  the  seventh  rib  is  a  strip 
of  slight  dulness  extending  from  the  seventh  to  the  ninth  rib.  I  have 
been  able  to  locate  it  in  infants  and  in  children  imder  the  age  of  six 
years.  There  can  be  no  question  as  to  its  existence,  although  there 
may  be  doubt  as  to  its  causation.  Symmington,  in  his  frozen  section, 
shows  that,  in  a  girl  six  years  of  age,  the  left  lobe  of  the  liver  is  dis- 
tinctly on  the  left  side  behind  the  seventh  and  ninth  ribs.  Sahli 
ascribes  the  strip  to  what  he  calls  the  deep  dulness  of  the  spleen. 
From  the  ninth  rib  downward,  there  is  absolute  dulness,  then  flatness, 
due  to  the  presence  of  the  spleen  proper  behind  the  chest  wall.     The 


DISEASES  OF  THE  SPLEEN. 


733 


anterior  border  of  the  spleen  is  located  by  percussing  in  a  horizontal 
direction  toward  the  axillary  line  along  the  tenth  rib. 

Palpation. — The  enlarged  spleen  can  be  distinctly  made  out  by 
palpation.  The  abdomen  should  be  relaxed.  It  is  sometimes  neces- 
sary to  flex  the  thighs  slightly,  in  order  to  relax  the  abdomen.  In 
young  infants  this  is  not  necessary. 

The  physician  stands  at  the  right  side  of  the  patient  and  with 
the  palmar  surface  of  the  fingers  of  the  right  hand  palpates  the  ab- 
dominal parietes  just  beneath  the  border  of  the  ribs  (Fig.  169).  As 
the  patient  inspires  deeply,  the  hand  is  by  steady  pressure  insinuated 
beneath  the  ribs  in  an  upward  and  backward  direction.  In  the  vast 
majority  of  cases  under  the  tenth  year,  the  normal  spleen  may  thus 
be  felt. 

Fig.  1G9. 


Method  of  palpating  the  spleen. 


In  practice,  it  may  safely  be  said  that  a  spleen  which  cannot  be 
felt  below  the  border  of  the  ribs  is  not  enlarged,  unless  some  con- 
dition, such  as  the  presence  of  fluid  or  tympanites,  prevents  thorough 
palpation,  I  have  rarely  failed  to  palpate  the  enlarged  spleen  satis- 
factorily. Enlargement  of  the  spleen  is  found  in  rachitis,  chronic 
gastro-enteritis,  sepsis,  typhoid  fever,  malarial  fever,  varicella,  syph- 
ilis, ansemia  infantum  pseudoleuka?mica,  leuksemia,  Hodgkin's  dis- 
ease, congenital  syphilis,  cirrhosis  of  the  liver,  amyloid  degeneration, 
heart  disease,  and  simple  catarrhal  jaundice. 

From  these  statements  it  will  be  seen  that  enlargement  of  the 
spleen  in  infancy  and  childhood  is  pathognomonic  of  no  one  disease, 
and  should  not  lead  to  any  one  conclusion.  It  is  only  corroborative 
in  the  presence  of  other  signs  and  symptoms.  Without  a  very  thor- 
ough and  painstaking  examination  of  the  blood,  the  significance  of 
the  enlarged  spleen  in  the  febrile  and  afebrile  afi^ections  cannot  be 


734  LTMPE-NODES,  DUCTLESS  GLANDS  AND  BLOOD. 

determined.  In  enlargements  of  the  spleen  such  as  are  met  in 
rachitis,  heart  disease,  syphilis,  chronic  gastro-enteritis,  icterus,  vari- 
cella, examination  of  the  blood  may  not  be  necessary. 

Splenic  and  Kidney  Tumors. — In  rare  cases  in  which  sarcoma  of 
the  left  kidney  is  suspected,  it  may  be  necessary  to  exclude  tumor 
of  the  spleen. 

An  enlarged  spleen  is  smooth  on  the  surface  and  has  a  sharp  an- 
terior edge  interrupted  by  an  indentation — the  hilus.  The  tumor  is 
pointed  and  sharp  below.  It  can  be  grasped  deep  in  the  lumbar  re- 
gion behind. 

Kidney  tumors  are  irregular  on  the  surface  and  marked  out  into 
lobes,  some  of  which  may  be  cystic.  The  tumor  projects  upward 
behind  into  the  lower  part  of  the  chest.  The  whole  lumbar  region 
is  flat  on  percussion.  The  borders  of  the  tumor  are  rounded.  On 
the  other  hand,  I  have  made  an  autopsy  in  a  case  of  cirrhosis  of  the 
liver  and  spleen  in  which  the  latter  organ  during  life  showed  uneven 
tumors  on  its  surface  (gummata). 

The  physician  must  be  partly  guided  by  the  history  of  a  case. 
The  urine  should  be  examined  in  cases  of  sarcoma  of  the  kidney, 
and  the  blood  in  cases  of  enlarged  spleen.  I  have  seen  a  subphrenic 
abscess  displace  the  spleen  downward.  The  left  lobe  of  the  liver  was 
also  displaced  in  the  same  direction.  Under  anaesthesia,  a  round 
mass  could  be  felt  above  the  spleen,  which  was  enlarged.  Behind, 
the  lung  came  well  down  to  the  bottom  of  the  chest,  as  was  evinced 
by  the  presence  of  the  respiratory  murmur.  Dulness  was,  however, 
present  in  the  left  axillary  line  and  behind.  On  exploratory  puncture 
in  the  posterior  axillary  line,  the  subphrenic  abscess  was  found  to  be 
present. 

DISEASES  OF  THE  BLOOD. 

Leading  General  Characteristics  of  the  Blood  in  Infancy  and 
Childhood. — For  diagnostic  purposes,  it  is  important  to  bear  in  mind 
certain  characteristics  of  the  blood  in  infancy  and  childhood. 
Ehrlich  has  shown  that  conditions  normal  to  the  blood  in  early  life 
are  of  grave  import  if  found  in  the  adult. 

The  Red  Blood-cells  or  Erythrocytes. — During  the  first  three  days  of 
life,  nucleated  red  blood-cells  are  found  in  the  normal  blood.  In 
the  newly  born  infant,  the  red  blood-cells  number  from  4,500,000 
to  6,500,000  to  the  cubic  millimetre  (Hayem).  There  is  a  polycy- 
thaemia.  This  condition  is  found  during  the  first  few  days  of  life. 
On  the  fourteenth  day  there  is  an  average  of  5,500,000  red  blood- 
cells  to  the  cubic  millimetre.  From  the  second  to  the  tenth  year 
the  average  number  is  5,000,000  (Otto,  Schiff,  Sorenson).  The 
polycytha?mia  in  the  newly  born  infant  is  greater  if  the  tying  of 


DISEASES  OF  THE  BLOOD.  735 

the  umbilical  cord  is  delayed  until  its  pulsations  cease.  Weaklings 
show  a  diminished  number  of  red  blood-cells.  In  addition  to  imper- 
fect nutrition,  anaemia  of  any  kind,  acute  or  chronic  cachexia,  and 
certain  drugs,  such  as  antipyrin,  antifebrin,  phenacetin,  and  lacto- 
phenin,  reduce  the  number  of  red  blood-cells  by  disintegrating  a 
certain  proportion  of  them  (Monti).  Infectious  diseases,  such  as 
malaria,  scarlet  fever,  typhoid  fever,  and  sepsis,  have  a  similar 
influence.  In  severe  anaemia,  such  as  that  accompanying  rachitis, 
nucleated  red  blood-cells  appear  in  the  blood.  These  are  also  found 
in  the  severe  primary  ana?mias,  in  acute  leukaemia,  and  in  pernicious 
anaemia  of  infants  and  children. 

The  White  Blood-cells  or  Leucocytes. — The  number  of  leucocytes  in 
the  nev^ly  born  infant  is  high,  being  from  18,000  to  30,000  to  the 
cubic  millimetre  (Hayem,  Guppen).  It  gradually  falls  to  12,000  to 
the  cubic  millimetre,  the  average  for  infants.  The  percentage  of 
lymphocytes  is  at  first  small  in  comparison  with  that  of  the  poly- 
nuclear  leucocytes.  Gundobin,  whose  work  has  been  confirmed  by 
Carstanjen,  found  that  the  polynuclear  leucocytes  preponderate  in 
the  newborn  infant.  They  increase  and  reach  their  highest  figure  in 
the  first  forty-eight  hours  of  life.  They  then  diminish  in  number, 
while  the  mononuclear  lymphocytes  increase  proportionately  until  the 
seventh  or  tenth  day,  when  the  blood  assumes  the  characteristics 
which  distinguish  it  during  the  period  of  infancy.  During  infancy 
the  mononuclear  lymphocytes  are  more  numerous  than  the  polymor- 
phonuclear leucocytes.  The  following  table  is  taken  from  Gundobin's 
figures : 

Polymorphonuclear  Mononuclear  Transitional 

leucocytes.  lymphocytes.  forms. 

Immediately  after  birth  ...     63      per  cent.  25  per  cent.  12      per  cent. 

Forty-eight  hours  after  birth    .     70      per  cent.  21  per  cent.  19      per  cent. 

Infancy 34.6  per  cent.  59  per  cent.         6.4  per  cent. 

In  normal  infants  and  young  children,  the  number  of  leucocytes 
to  the  cubic  millimetre  may  vary  from  13,000  to  20,000  (Japha). 
The  so-called  digestive  leucocytosis  found  in  the  adult  is  inconstant 
in  infants  and  young  children  (Japha).  There  is  an  inflammatory 
leucocytosis  in  infants  and  children  similar  to  that  seen  in  the  adult. 
It  occurs  in  pneumonia,  scarlet  fever,  rheumatism,  sepsis,  diphtheria, 
post-hemorrhagic  anaemia,  and  cachexia  (sarcoma).  In  the  normal 
state,  the  leucocytes  may  reach  a  minimum  of  6000  to  the  cubic  milli- 
metre (Monti).  This  fact  should  be  borne  in  mind  in  estimating  the 
leucopoenia  in  typhoid  fever,  malaria,  tuberculosis,  and  in  other  infec- 
tious or  toxic  states. 

The  transitional  forms  of  leucocytes  are  numerous  in  the  newly 
born  infant,  reaching  their  maximum  from  the  sixth  to  the  ninth 
day.  The  eosinophiles  are  present  in  the  same  number  as  in  later 
life  (Japha). 


736  LYMPE-NODES,  DUCTLESS  GLANDS  AND  BLOOD. 

The  HEemoglobin. — The  blood  is  richer  in  hsemoglobin  at  birth 
than  later  in  life  (Morse,  Leichtenstern,  Eotch).  After  birth  the 
percentage  of  haemoglobin  sinks,  and  at  the  third  month  reaches  that 
of  later  Hfe.  Carstanjen  found  the  haemoglobin  on  the  average  100 
per  cent,  up  to  the  twelfth  day.  The  lowest  percentages  are  found 
from  the  sixth  month  to  the  second  year.  There  is,  in  exceptional 
cases  in  normal  children,  a  very  high  percentage  from  the  fifth  to  the 
tenth  year,  ranging  from  95  to  110  (Widowitz,  Leichtenstern,  Hock, 
and  Schlessinger).  The  percentage  in  healthy  children  may  be  as 
low  as  60  (Fleischl)  or  8.4  grammes  to  100  c.c.  of  blood.  At  the 
third  month  of  infancy  it  may  range  from  69  to  94;  up  to  the  second 
year  it  may  range  from  62  to  81  (Monti).  There  seems  to  be  no 
fixed  normal  limit.  Anaemia  or  toxsemia  of  any  kind  and  infectious 
diseases  diminish  the  hgemoglobin. 

The  Specific  Gravity. — The  exact  clinical  significance  of  the  spe- 
cific gTavity  of  the  blood  is  little  understood.  The  specific  gravity 
is  high  in  the  newly  born  infant,  ranging  from  1.056  to  1.066.  From 
the  sixth  month  to  the  tenth  year  it  varies  from  1.050  to  1.056 
(Monti).  These  figures  correspond  to  those  of  Hock,  Schlessinger, 
Lloyd,  Jones,  and  others.  The  blood  of  strong  children  and  breast-fed 
infants  has  a  higher  specific  gravity.  Diarrhoea  may  raise  it,  but 
rarely  to  a  ratio  of  more  than  0.004  part  per  1000.  The  specific 
gravity  is  increased  in  the  infectious  diseases,  pneumonia,  pleuritis, 
endocarditis,  typhoid  fever,  and  tuberculous  meningitis,  and  falls  on 
the  decline  of  these  processes.  It  is  also  increased  in  congenital  heart 
disease,  chorea  with  endocarditis,  icterus,  and  diphtheria.  It  dim- 
inishes with  the  loss  in  weight  accompanying  anaemia  and  nephritis, 
and  in  cachexia  (Hock,  Schlessinger,  Monti,  Hammersley,  and 
Felsenthal). 

Anaemia. — Anaemia  is  a  condition  resulting  from  a  deficiency  in 
the  blood  of  one  or  more  of  its  constituent  elements.  It  may  be  either 
congenital  or  acquired.  In  the  latter  case  it  may  either  be  secondary 
to  other  conditions  or  occur  as  a  primary  disease.  Congenital  anaemia 
is  seen  at  birth  in  infants  born  of  badly  nourished  mothers,  who  dur- 
ing pregnancy  have  suffered  from  some  disease  of  the  placenta,  or 
from  syphilis,  tuberculosis,  or  malaria.  The  foetus  in  utero  becomes 
anaemic.  Acquired  anaemia  appears  after  birth.  It  is  either  sec- 
ondary to  some  acute  loss  of  blood  (post-hemorrhagic),  to  chronic  loss 
of  blood,  or  is  caused  by  defective  nutrition,  unhygienic  surroundings, 
diseases  of  the  various  organs,  toxaemia,  infectious  diseases,  or 
parasites. 

Primary  or  essential  anaemia  is  the  form  in  which  the  changes  in 
the  blood  play  so  important  a  role  that  it  is  assumed  there  is  a  dis- 
ease of  the  blood  itself  or  of  the  blood-forming  organs.  Such  are  the 
forms  of  leukaemia,  chlorosis,  and  pernicious  anaemia. 


DISEASES  OF  THE  BLOOD.  737 

Simple  Anaemia  (Secondary  Anoemia). — Etiology. — Secondary 
simple  aiisemia  may  follow  some  acute  or  chronic  loss  of  blood.  In 
acute  post-hemoTrhagic  anaemia,  the  increase  of  fluid  elements  keeps 
pace  with  the  loss  of  blood  if  the  loss,  though  small,  is  repeated  at 
short  intervals.  Children  show  the  effects  of  loss  of  blood  much  more 
quickly  than  adults.  Hydrsemia  is  the  condition  which  results  when 
the  loss  is  marked.  The  fluid  elements  increase,  and  there  is  a 
diminution  in  the  specific  gravity  of  the  blood  and  in  the  amount  of 
hsemogiobin.  Hydrasmia  may  result  in  children  without  hemorrhage ; 
that  is  to  say,  it  may  occur  in  extreme  severe  anaemia  secondary  to 
some  disturbance  of  nutrition  or  to  illness.  In  post-hemorrhagic 
anaemia  the  coagulability  of  the  blood  is  increased  immediately  after 
the  hemorrhage.  Ehrlich  supposes  this  to  be  due  to  an  increase  in  the 
number  of  blood-plates.  After  the  hemorrhage,  the  regeneration  of 
blood  in  the  infant,  as  in  the  adult,  is  indicated  by  the  formation  or 
appearance  in  the  blood  of  microcytes,  megalocytes,  and  nucleated 
red  blood-cells  (normoblasts).  The  severe  forms  of  this  variety  of 
anaemia  also  show  polychromatophilic  properties  of  the  red  blood-cells. 
These  are  so  poor  in  haemoglobin  that  with  various  stains  the  normal 
reaction  is  very  much  changed.  There  are  various  shades  of  the 
stained  red  blood-cells.  In  recent  and  severe  cases  of  post-hemorrha- 
gic anaemia  there  may  be  leucocytosis.  There  is  an  increase  of  the 
polynuclear  neutrophilic  leucocytes  (Monti,  Ehrlich).  iSTucleated 
red  blood-cells  (normoblasts)  may  appear  in  severe  cases.  Poikilocy- 
tosis  is  also  one  of  the  changes  seen  in  the  blood. 

Secondary  anaemia  of  a  mild  or  of  a  severe  type  is  also  seen  in 
infants  and  children  who  suffer  from  defective  nutrition.  It  com- 
plicates or  accompanies  rachitis,  syphilis,  scrofula,  tuberculosis, 
gastro-intestinal  catarrh,  chronic  endocarditis,  purpura,  morbus 
Werlhofii,  and  infectious  diseases. 

Symptoms. — The  symptoms  of  mild  anaemia  in  infants  and  chil- 
dren do  not  differ  materially  from  those  of  adults.  The  patient  is 
pale  and  the  mucous  membranes  have  a  characteristic  pallor.  The 
appetite  is  capricious.  The  patients  also  suffer  from  symptoms  due 
to  the  primary  affection — syphilis,  rachitis,  acute  infectious  disease, 
gastro-enteric  disturbance  (acute  or  chronic),  or  cardiac  affection. 
The  pallor  of  cardiac  disease  or  nephritis  is  characteristic  in  infants 
and  children,  as  in  the  adult. 

The  anaemia  if  of  a  severe  type  takes  the  hydraemic  form.  In 
the  severe  forms  of  anaemia,  especially  in  infants  and  very  young 
children  who  suffer  from  syphilis  or  rachitis,  the  skin  is  waxy  or  yel- 
lowish white.  The  ears  are  absolutely  devoid  of  any  color  of  blood. 
In  cretinism  the  skin  has  a  greenish-yellow  hue.  Infants  do  not 
show  the  symptoms,  such  as  dyspnoea  or  palpitation,  seen  in  older 

47 


738  LYMPH-NODES,  DUCTLESS  GLANDS  AND  BLOOD. 

children  on  exertion.  The  muscles  are  flabby  and  there  is  a  disposi- 
tion to  lie  quietly  in  the  crib.  The  spleen  may  be  large,  and  the  liver 
also,  especially  if  rachitis  or  syj)hilis  is  present.  In  cases  in  which 
the  anaemia  is  extreme,  the  spleen  may  be  normal. 

Infants  and  very  young  children  do  not  always  show  the  anaemic 
murmurs  which  are  heard  over  the  heart  area  in  older  children.  In 
older  children  murmurs  of  that  variety  may  be  present  with  a  venous 
hum  in  the  neck,  and  the  symptoms  of  mild  and  severe  anaemia  are 
essentially  those  of  later  life.  These  are  indisposition  to  exertion, 
feelings  of  weakness,  drowsiness,  lack  of  appetite,  irritability,  and 
restlessness.  Some  of  the  severe  forms  of  anemia  show  for  weeks  a 
very  slight  irregular  febrile  curve.  In  many  cases  the  fever  is  due 
to  intestinal  toxaemia. 

The  Blood. — The  mild  forms  of  simple  anaemia  may  show  only 
a  diminution  in  the  amount  of  haemoglobin,  a  very  slight  diminution 
in  the  number  of  red  cells,  a  reduction  of  the  specific  gravity,  and  if 
there  is  a  primary  affection  which,  like  pneumonia,  causes  an  increase 
in  the  number  of  leucocytes,  leucocytosis.  My  records  of  severe 
forms  of  anaemia  in  infants  and  young  children  show  a  diminution 
in  the  amount  of  haemoglobin  (18  per  cent.).  The  blood  shows 
microcytes,  megalocytes,  megaloblasts,  and  normoblasts.  Increase 
of  mononuclear  lymphocytes  is  proportionate  to  that  of  the  poly- 
nuclear  leucocytes.  Poikilocytosis/in  various  forms  is  present,  as  are 
also  polychromatophilic  phenomena.  In  the  severe  forms  of  anaemia 
due  to  malarial  poisoning  I  found,  in  addition  to  the  plasmodium. 
microcytes,  megalocytes,  and  megaloblasts.  The  eosinophiles  are  not 
increased.  In  severe  anaemia,  the  physical  characteristics  of  the 
blood  are  striking.  It  may  be  so  thin  as  to  seperate  on  puncture  into 
a  reddish  and  a  colorless  portion  resembling  beef-water. 

Chlorosis.- — Chlorosis  is  a  form  of  primary  anaemia.  It  is  not  a 
disease  of  infancy  or  childhood,  and  is  mentioned  here  only  in  order 
to  complete  the  classification  of  diseases  of  the  blood.  Its  etiology 
is  obscure.  Virchow  believed  it  to  be  due  to  congenital  narrowness  of 
the  whole  arterial  system  and  smallness  of  the  heart.  This  theory 
does  not  explain  the  cases  in  which  recovery  takes  place.  Meinert 
ascribed  the  condition  to  an  irritation  of  the  abdominal  sympathetic. 
Hofman  thought  that  developmental  conditions  of  the  genital  ap- 
paratus were  causal  in  chlorosis.  Forcheimer  contends  that  intestinal 
auto-infection  is  etiological  in  producing  the  chlorotic  state,  since 
there  is  in  chlorosis  an  interference  with  the  production  of  haemo- 
globin, the  principal  source  of  which  is  the  gut. 

Occurrence. — Chlorosis  is  more  common  in  females  than  in  males, 
and  occurs  at  the  time  of  puberty. 

The  condition  of  the  blood  has  been  described  bv  Monti.      The 


DISEASES  OF  THE  BLOOD. 


739 


hsemoglobin  is  diminished.  The  number  of  red  blood-cells  is  in  mild 
cases  scarcely  at  all  reduced.  In  severe  cases  it  may  fall  to  1,000,000 
to  the  cubic  millimetre.  The  absolute  amount  of  hsemoglobin  may 
reach  4  to  8  in  100  cubic  millimetres  of  blood.  The  specific  weight 
may  be  reduced  to  1035.     There  are  niicrocytes  in  the  blood.     There 

Fig.  170. 


Pseudoleuksemic  anajmia,  enlarged  spleen  and  liver. 

is  no  leucocytosis.     There  are  poikilocytosis  and  polychromatophilic 
appearances  in  the  stained  blood. 

Pseudoleuksemic  Anaemia  of  von  Jaksch  (Ancemia  Infantum 
•Pseudolev.Jccemica.) — In  1889  von  Jaksch  described  a  symptom-com- 
plex met  with  among  infants  and  young  children,  to  which  he  gave 


740  LTMPH-XODES,  DUCTLESS  GLANDS  AND  BLOOD. 

the  name  of  anaemia  infantum  psendoleuksemica.  He  described  the 
condition  as  a  clinical  entity  which,  in  running  its  course,  gives  the 
picture  of  severe  ljmj)hatic  angemia.  There  are  enormous  enlarge- 
ment of  the  spleen,  slight  enlargement  of  the  liver,  some  enlargement 
of  the  lymph-nodes,  and  changes  in  the  blood.  It  is  a  secondary 
anaemia  rather  than  a  distinct  disease.  For  this  reason  Fischl, 
Epstein,  and  others  deny  that  it  is  a  clinical  entity.  On  the  other 
hand,  Monti  and  Luzet  have  described  numbers  of  cases.  I  have 
records  of  9  cases,  which  were  published.     The  aneemia  is  extreme. 

Etiology. — It  is  difficult  to  determine  the  etiology.  Von  Jaksch 
and  Monti  trace  an  intimate  connection  between  this  condition  and 
rachitis.  Wentworth  and  the  Italian  school  regard  it  as  secondary  to 
some  form  of  intestinal  infection. 

Occurrence. — The  condition  is  rarely  found  before  the  age  of 
six  months.  My  cases  ranged  from  the  ages  of  eleven  to  twenty 
months.  It  may  occur  up  to  the  third  year,  and  is  most  common  from 
the  seventh  to  the  twelfth  month.  Most  of  the  cases  thus  far  pub- 
lished have  occurred  in  infants  or  children  suffering  from  rachitis  or 
congenital  syphilis.  In  all  of  my  cases  there  were  signs  of  rachitis. 
Some  of  the  children  had  previously  suffered  from  chronic  gastro- 
enteric derangement. 

Morbid  Anatomy. — The  post-mortem  findings  published  by  von 
Jaksch,  Luzet,  Baginsky,  Holt,  Glockner,  Lehndorf,  and  the  writer 
correspond  very  closely. 

The  spleen  was  large  and  firm,  the  liver  hard  and  enlarged,  and 
the  mesenteric  lymph-nodes  were  enlarged.  A  histological  exami- 
nation revealed  the  bone-marrow  rich  in  cells ;  there  were  normo- 
blasts, leukocytes  with  granules  and  those  without  granules ;  there 
were  myelocytes,  eosinophiles,  and  giant  cells,  also  cells  containing 
pigment.  The  marrow  was  a  richly  cellular  mixed  marrow.  The 
liver  cells  were  normal;  there  were  nucleated  red  blood  cells  in  the 
capillaries,  and  myelocytes.  The  kidney  showed  parenchymatous 
degeneration,  the  heart  was  negative,  the  lungs  showed  peribronchitic 
infiltration,  the  spleen  showed  increased  connective  tissue,  pulp  rich 
in  cells,  capillaries  dilated,  eosinophiles  present  in  moderate  numbers, 
nothing  abnormal  found.  Lehndorf  was  inclined,  from  the  appear- 
ances, to  regard  the  anatomical  diagnosis  of  myelemia,  especially 
supported  by  the  appearances  found  in  the  liver,  and  kidney,  although 
the  spleen  and  lymph-nodes  were  less  affected,  and  there  was  no 
siderosis.  It  will  be  shown  later  on  how  little  justified  this  conclusion 
was. 

Symptoms. — The  infants  affected  have  as  a  rule  suffered  from 
chronic  intestinal  disturbances.  Most  of  them  are  bottle-fed  and 
atrophic.     Although  the  skin  is  intensely  anaemic  and  of  a  yellow, 


DISEASES  OF  THE  BLOOD.  741 

waxy  tinge,  there  is  sometimes  a  panniciiius  of  fat.  The  musculature 
is  flabby  and  the  abdomen  large.  As  a  rule  there  are  signs  of  rachitis. 
The  fontanelle  is  open  and  the  eruption  of  the  teeth  delayed.  The 
infants  are  irritable,  peevish,  do  not  willingly  take  food,  and  do  not 
assimilate  it.    In  one  of  my  cases,  there  was  complicating  pneumonia. 

There  is,  as  a  rule,  no  fever,  unless  it  is  due  to  intestinal  toxaemia. 
The  picture  is  one  of  progressive  emaciation  and  anemia.  In  some 
cases  there  is  complicating  icterus,  and  the  spleen  reaches  to  the  crest 
of  the  ileum.  The  edge  of  the  spleen  is  sharp  and  the  hilus  can  be 
distinctly  felt.  The  liver  is  slightly  enlarged;  its  edge  is  round  and 
smooth.  In  one  of  my  cases,  it  extended  two  and  one-half  inches 
below  the  free  border  of  the  ribs  (Fig.  170).  The  lymph-nodes  in 
the  groin  and  axillse  are  slightly  enlarged,  sometimes  only  to  the 
size  of  a  bean. 

The  Blood. — The  specific  gravity  of  the  blood  is  reduced.  The 
haemoglobin  may  be  reduced  to  one-quarter  the  normal  percentage. 
It  may  be  as  low  as  17  per  cent.  There  is  a  marked  diminution  of 
the  number  of  red  blood-cells.  The  nucleated  forms  of  erythrocytes 
are  abundant.  There  are  megaloblasts,  which  show  karyokinesis. 
In  addition  there  are  red  blood-cells  of  all  sizes — microcytes  and 
megalocytes.  There  is  poikilocytosis  to  a  marked  degree,  and  also 
polychromatophilia.  The  leucocytes  are  only  moderately  increased. 
In  the  severe  cases  the  proportion  of  white  blood-cells  to  the  red  may 
be  as  1:100,  1:80,  or  1:15  (Monti).  The  picture  given  by  the 
leucocytes  is  different  from  that  of  leukaemia.  Most  authors  agree 
that  the  various  forms  are  represented  and  increased  in  equal  ratio. 

In  my  nine  cases  the  blood-picture  was  as  follows :  The  hemo- 
globin ranged  from  28  to  65  per  cent.;  the  count  of  red  blood-cells 
or  erythrocytes  fell  as  low  as  1,400,000  and  in  others  was  as  high  as 
4,448,000 ;  and  the  leucocytes  ranged  from  5,200  to  7,500  to  40,000 
and  80,000  to  the  cubic  millimeter.  In  all  cases  there  were  nucleated 
red  blood-cells,  normoblasts,  and  megaloblasts  from  7  to  15  per  cent. 
In  some  cases  the  white  cells  varied  from  11,000  to  80,000  to  the 
cubic  millimeter  in  a  given  case,  with  erythrocyte  count  of  2,600,000 
to  3,700,000. 

Some  writers  think  there  is  a  predominance  of  polynuclear  leuco- 
cytes, but  this  is  scarcely  so,  as  in  some  cases  they  comprised  80  per 
cent,  of  the  white  blood  cells,  while  in  others  they  fell  as  low  as  14  to 
15  per  cent.  This  may  occur  in  the  same  case  in  which  blood-counts 
have  been  taken  a  few  days  apart.  A  leucocytosis  or  a  polynuclear 
leucocytosis,  therefore,  is  of  no  diagnostic  import. 

The  myelocytes  were  present  in  all  cases,  varying  in  frequency 
from  -J  per  cent,  to  7  per  cent.  In  some  cases  at  different  times  the 
myelocytes  varied  from  -J  per  cent,  to  4^  per  cent,  in  different  counts. 


742  LTMPE-NODES,  DUCTLESS  GLANDS  AND  BLOOD. 

It  has  been  shown  elsewhere  that  the  myelocytes,  also,  are  not  of 
specific  value  as  differentiating  these  cases  from  other  cases  of  severe 
anaemia,  and  the  variation  in  the  same  case,  at  different  times  of  the 
percentage  of  these  cells,  would  tend  to  confirm  this  view. 

The  eosinophiles  were  present  in  normal  percentages  in  all  the 
cases. 

Mast  cells  were  present  in  all  cases  in  percentages  varying  from 
1  per  cent,  to  4  per  cent. 

A  study  of  the  blood  pictures  in  my  uncomplicated  cases  only 
tends  to  confirm  the  belief  expressed  by  others  that  the  blood  picture 
in  this  disease  is  not  a  definite  pathological  picture  of  anything  but  a 
severe  anaemia  in  children  in  whom  any  disturbances  of  the  functions 
of  the  blood-forming  organs  causes  a  retrogi-ade  to  the  fcetal  structure. 

A  comparison  of  the  above  blood  pictures  with  those  published 
by  Lehndorf,  Fowler,  Monti  and  Berggriin,  Zelenski  and  Cybulski 
show  a  remarkable  correspondence,  and  prove  my  contention  that 
though  the  blood  picture  is  not  specific,  the  clinical  features  of  these 
cases  are  characteristic,  inasmuch  as  so  many  observers  agree  as  to 
the  physical,  clinical  signs. 

Diagnosis  and  Course. — The  clinical  picture  presented  by  cases  of 
anaemia,  described  by  Von  Jaksch,  and  following  him  by  writers 
mentioned,  is  certainly  easy  of  recognition. 

The  anaemic  habitus,  the  tumored  abdomen,  the  spleen  of  enor- 
mous size,  the  increased  size  of  the  liver,  the  intestinal  disturbances, 
easily  enable  us  to  recognize  such  cases  apart  from  the  cases  of 
slight  anaemia,  with  moderate  enlargement  of  the  spleen.  There  is 
nothing,  however,  in  these  cases  which  suggests  leukaemia,  except  it  be 
the  large  liver  and  spleen.  The  course  of  some  of  these  cases  result- 
ing in  complete  and  satisfactory  recovery,  certainly  impresses  me 
with  the  fact  that  the  condition  is  rather  one  of  a  severe  disturbance 
of  the  nutritive  functions  of  certain  organs,  such  as  the  intestine,  and 
its  large  secretive  glandular  system,  reacting  upon  certain  organs, 
such  as  the  spleen,  causing  changes  in  the  same,  with  secondary 
changes  in  the  blood,  which  may  assume  a  role  of  primary  impor- 
tance. 

Von  Jaksch's  anaemia  is,  therefore,  a  severe  secondary  anaemia, 
with  or  without  marked  leucocytosis.  Those  cases  which  have  been 
reported  as  terminating  in  true  leukaemia  were  really  cases  of  leukae- 
mia from  the  outset.  Cases  of  true  Von  Jaksch  disease,  if  they 
terminate  fatally,  do  so  from  some  intercurrent  disease,  such  as 
pneumonia  or  tuberculosis,  to  which  they  fall  easy  victims. 

Treatment. — Thus  far  the  treatment  has  been  empirical.  Small 
doses  of  Fowler's  solution  are  indicated.  If  rachitis  is  present, 
phosphorus  is  given  by  some  in  small  doses.     I  have  seen  cases  do 


DISEASES  OF  THE  BLOOD.  743 

badly  under  that  treatment.  Tonics  and  an  easily  assimilable  diet 
are  indicated.  The  bowels  should  be  kept  clear  by  enemata  given 
daily  in  order  to  lessen  the  possibility  of  infection  of  the  gut. 

Leukaemia  (Leukocythaemia). — Leukaemia  is  a  persistent  condi- 
tion of  the  blood  in  which  there  is  an  increase  of  the  white  blood- 
cells,  and  a  diminution  of  the  red  ones.  It  is  a  primary  disease  of 
the  blood  itself.  Accompanying  it  are  changes  in  the  spleen,  liver, 
bone-marrow,  lymph-nodes,  and  lymphoid  tissues.  Virchow  called 
the  condition  "white  blood."  French  writers  have  called  it  leukocy- 
thaemia. The  proportion  between  the  white  and  the  red  blood-cells 
is  not  so  distinguishing  a  feature  as  the  appearance  of  large  numbers 
of  lymphocytes  in  the  blood,  in  which  they  are  normally  present  in 
only  small  numbers.  In  one  form  the  appearance  of  mononuclear 
neutrophile-staining  myelocytes  which  are  normally  absent  is  a  dis- 
tinguishing feature.  Ehrlich  characterizes  leukaemia  as  a  mixed 
leucocytosis  of  chronic  course,  since  white  blood-cells  of  all  kinds  are 
present  in  the  blood.  This  is  not  the  case  in  the  polynuclear  and 
eosinophile  leucocytosis. 

Occurrence. — The  disease  is  rare  in  childhood,  but  some  authors 
believe  it  to  be  more  common  in  the  first  year  of  life  than  is  generally 
supposed  (Monti,  Mosler).  Fifteen  to  20  per  cent,  of  the  cases  occur 
in  the  first  decade  of  life  (Baginsky).  Males  are  more  frequently 
affected  than  females.    The  disease  is  believed  to  be  hereditary. 

Etiology. — The  etiology  of  the  affection  is  still  unknown.  In  a 
few  cases,  micro-organisms  and  sporozoa  have  been  found  in  the  blood 
(Eoux,  Kelsch,  Veillard,  Lowit).  The  sporozoa  of  Lowit  are  de- 
scribed by  him  as  being  free  in  the  blood  as  well  as  in  the  leucocytes 
and  in  the  blood-making  organs.  In  lymphatic  leukaemia  they  are 
described  as  being  intracellular  only.  Auer  has  described  intracellu- 
lar bodies  in  the  leucocytes  resembling  capsulated  bacteria. 

Some  writers  think  that  rachitis  and  syphilis  predispose  to  the 
development  of  leukaemia,  especially  if  the  bones  are  involved  as  well 
as  the  liver,  spleen,  and  lymph-nodes.  Certain  forms  of  anaemia  fol- 
lowing malaria,  diphtheria,  and  scarlet  fever,  and  accompanied  by 
enlargement  of  the  liver,  spleen,  and  lymph-nodes,  may,  according 
to  some  writers,  pave  the  way  for  leukaemia.  Physical  or  mental 
strain,  unhygienic  living,  defective  nutrition,  and  traumatism  of  the 
spleen,  have  all  been  regarded  as  predisposing  factors. 

Forms. — The  simplest  classification  of  leukaemia  is  that  based 
upon  the  anatomical  appearances  of  the  blood.  Such  is  the  classifica- 
tion of  Ehrlich,  which  is  as  follows : 

(a)  Lymphatic  leukaemia,  in  which  there  is  a  marked  hyper- 
plasia of  lymphoid  tissue. 

(&)   Myelogenous  leukaemia,   in  which  there   is  hyperplasia   of 


744  LYMPH-NODES,  DUCTLESS  GLANDS  AND  BLOOD. 

myelogenous  tissue.  Ljmphatic  kuksemia  may  run  an  acute  or  a 
chronic  course.  In  both  forms  the  distinguishing  feature  is  the 
appearance  in  the  blood  of  large  numbers  of  the  mononuclear  lym- 
phocytes and  the  displacement  of  the  polynuclear  leucocytes.  The 
acute  form  is  rare.  It  occurs  in  childhood.  Eight  cases  have  oc- 
curred in  my  hospital  service  in  the  past  six  years.  Its  course  is 
rapid.  There  are  slight  or  marked  tumor  of  the  spleen,  slight  or  very 
marked  enlargement  of  the  liver,  and  a  tendency  to  petechise  and  to 
general  hemorrhages.  Some  authors  regard  these  cases  as  infectious. 
The  chronic  forms  show  marked  enlargement  of  the  spleen. 

Changes  in  the  Blood, ^ — As  was  previously  stated,  the  lymphatic 
forms  of  leukaemia  are  distinguished  by  the  appearance,  in  the  blood, 
of  large  numbers  of  the  small  and  large  mononuclear  lymphocytes. 
In  the  myelogenous  forms,  a  cell  which  is  normally  not  present  in  the 
blood,  but  is  indigenous  to  the  bone-marrow,  appears  in  large  num- 
bers. This  cell  is  the  large  mononuclear  neutrophilic  staining  cell, 
the  myelocyte  of  Ehrlich.  The  mast-cells  are  also  found  in  these 
cases,  but  are  not  peculiar  to  this  form  of  anaemia.  In  addition  there 
is  in  the  myelogenous  forms  of  leukaemia  an  increase  in  the  number 
of  all  three  types  of  granulated  white  cells,  the  neutrophiles,  the 
eosinophiles,  and  the  mast-cells.  There  are  dwarf  forms  of  the  white 
blood-cells,  mitoses,  and  lastly  large  numbers  of  nucleated  red  blood- 
cells,  l^ormoblasts,  megaloblasts,  and  myelocytes  are  not  normally' 
present  in  the  blood.  They  are  occasionally  found  in  penumonia, 
and  in  leucocytosis.  The  eosinophiles  are  increased  to  fifteen  times 
their  normal  number.  The  slow  coagulability  of  leuksemic  blood  is 
characteristic. 

The  spleen  is  enlarged.  It  is  at  first  soft,  often  firm,  and  is 
infiltrated  with  lymph-cells.  The  capsule  is  thickened;  the  connec- 
tive-tissue stroma  is  increased  and  infiltrated  with  lymph-cells.  The 
lymph-nodes  show  similar  changes,  and  may  be  enlarged,  forming 
tumors  of  considerable  size. 

The  bone-marrow  is  so  infiltrated  with  lymph-cells  as  to  acquire 
the  appearance  of  a  purulent  infiltration.  The  same  lymphoid  infil- 
tration is  found  in  the  liver.  The  follicles  of  the  gut  are  swollen. 
There  is  an  increase  of  lymphoid  cells  and  tissues.  The  lymphoid 
tissues  elsewhere,  such  as  the  tonsils,  thymus,  skin,  and  even  the 
retina,  show  the  same  changes.  There  are  hemorrhages  and  exudate 
in  the  ear,  and  the  nerves  and  nervous  tissue  of  the  central  nervous 
system  are  the  seat  of  lymphoid  cellular  invasion. 

Symptoms. — The  Acute  Form. — Cases  of  acute  leukaemia  in 
infancy  and  childhood  have  lately  been  increasing  in  the  literature. 
The  most  recent  cases  include  those  of  McCrae,  in  a  boy  aged  three 
years,  and  of  Miller,  in  an  infant  of  eight  months.     Cases  have  also 


DISEASES  OF  THE  BLOOD. 


745 


been  reported  by  Morse,  Japha,  Strauss,  Monti,  Berggriin.  The  most 
frequent  is  the  lymphatic  form.  The  symptoms  in  all  the  published 
cases  were  similar.  In  a  boy  eight  years  old,  admitted  to  my  hospital 
service,  there  were  no  premonitory  symptoms.  Two  months  before 
admission  he  was  in  good  health.  He  became  very  pale,  there  were 
irritability  and  loss  of  appetite,  and  the  abdomen  increased  markedly 
in  size.  He  complained  of  pains  in  the  legs,  and  at  the  onset  had 
chills  and  fever  every  other  day.     After  the  appearance  of  the  chills 


Fig.  171. 


Acute    lymphatic   leuksemia. 


Enlarged    lymph-nodes,   spleen,    and    liver, 
one-half  years  of  age. 


Boy   four   and 


he  suffered  from  a  low  irregular  fever.  A  week  before  death,  the 
skin  had  a  waxy  color,  there  were  petechise  on  the  extremities,  the 
gums  bled  easily,  and  the  lymph-nodes  of  the  axillae  and  groin  were 
enlarged.  There  was  an  ansemic  murmur  with  the  first  sound  of  the 
heart ;  the  liver  was  enlarged  below  the  free  border  of  the  ribs  to  the 
extent  of  two  fingers'  breadth ;  the  spleen  was  enlarged  to  the  level  of 
the  umbilicus;  the  fundus  of  the  eye  showed  retinal  hemorrhages. 
Examination  of  the  blood  showed  the  haemoglobin  to  be  reduced  to  15 


746  LYMPH-NODES,  DUCTLESS  GLANDS  AND  BLOOD. 

per  cent.  (Fleisclil).  The  red  blood-cells  numbered  1,012,000  to  the 
cubic  millimetre ;  the  white  blood-cells,  37,000.  There  was  an  im- 
mense preponderance  of  lymphocytes  (mononuclear).  The  patient 
died  with  signs  of  progressive  weakness.  Coma  was  preceded  by 
vomiting  and  the  appearance  of  a  few  petechise.  The  blood  state 
continued  much  the  same  as  at  first.  In  another  case  the  number  of 
mononuclear  lymphocytes  was  fully  75  per  cent,  of  the  white  blood- 
cells. 

In  both  these  cases  the  spleen  and  liver  diminished  in  size  before 
death.  The  proportion  of  white,  to  red  blood-cells  may  not  be  far 
from  normal.  In  another  case  the  nucleated  red  blood-cells,  large  and 
small,  were  very  numerous.  In  this  case,  in  a  boy  of  four  and  one-half 
years,  the  nodes  around  the  parotid  and  angle  of  the  jaw,  in  the 
axilla,  and  in  the  inguinal  region,  increased  in  a  short  time  to  a  large 
size,  and  the  spleen  grew  rapidly  larger  and  reached  to  the  crest  of 
the  ilium.  The  liver  reached  to  the  umbilicus.  These  mediastinal 
lymph-nodes  were  enlarged  and  caused  great  dyspnoea.  The  distress 
way  very  great  just  before  the  lethal  issue  (Fig.  171).  In  a  case  of 
V.  JSToorden's  the  proportion  of  the  white  to  the  red  blood-cells  was 
1 :  200.  The  predominance  of  the  lymphocytes  is  diagnostic.  Most 
of  the  cases  published  showed  a  slight  temperature.  The  fatal  issue 
usually  results  a  few  weeks  or  a  month  or  two  after  the  onset  of 
symptoms. 

The  Chronic  Form.- — The  symptoms  of  the  chronic  form  extend 
over  a  greater  length  of  time.  For  months  there  are  ansemia,  lassi- 
tude, and  extreme  physical  weakness.  The  appetite  is  good,  but  in 
spite  of  abundant  nourishment,  emaciation  is  progressive.  In  some 
eases  there  are  periodic  diarrhceal  attacks.  Profuse  hemorrhage  may 
occur  without  warning  either  from  the  nose  or  intestines.  Chills  and 
fever  resembling  those  of  paludism  are  sometimes  present.  ITone  of 
these  symptoms  is  particularly  characteristic. 

As  the  disease  progresses  there  are  headache  and  pain  in  the  limbs 
and  in  the  region  of  the  spleen.  The  ansemia  after  a  time  assumes  a 
severe  type,  and  the  skin  becomes  waxy  and  yellow.  At  this  stage 
the  spleen  and  liver  enlarge  and  distend  the  abdomen.  There  are 
dyspnoea  and  palpitation;  the  ansemia  takes  the  hydrsemic  form,  and 
there  is  oedema  of  the  face,  hands,  and  feet.  Hemorrhages  then  occur 
from  the  nose,  lungs,  mouth,  intestines,  but  rarely  from  the  kidneys. 
There  are  petechise  in  the  skin  and  hemorrhages  in  the  retina. 

In  the  lymphatic  form  the  lymph-nodes  in  various  parts  of  the 
body  enlarge  and  form  masses  which  are  painless  and  covered  with 
unaffected  skin.  The  skin  may  be  affected  by  the  process.  The 
mesenteric  nodes  may  sometimes  be  felt  through  the  abdomen.  The 
spleen  attains  an  enormous  size.     The  liver  may  extend  as  far  as  the 


PLATE  XXXIII 


w*^ 


Hodgkin's  Disease  in  a  Child. 


DISEASES  OF  THE  BLOOD.  747 

umbilicus.  Eespiratory  difficulties,  heart  weakness,  and  nervous 
symptoms  (such  as  vertigo,  somnolence,  and  coma)  end  the  clinical 
course  of  the  disease.  The  urine  is  diminished,  and  contains  hyaline 
casts,  lymphoid  cells,  and  a  trace  of  albumin.  There  may  be  a  slight 
continued  fever  in  the  course  of  the  disease. 

Prognosis. — The  prognosis  is  unfavorable.  Of  39  cases  collected 
by  Birch-Hirschfeld,  only  4  recovered.  Only  in  the  early  stage  is 
recovery  possible.  Death  supervenes  from  exhaustion  with  hemor- 
rhages or  from  intercurrent  pleuritis  or  pericarditis. 

Treatment. — The  treatment  of  a  disease  whose  exact  nature  is  still 
unknown  is  difficult.  Good  food,  and  hygienic  surroundings  are  the 
first  requisite.  In  the  treatment  of  anaemia,  the  iodide  of  iron,  cod- 
liver  oil,  and  arsenic  are  the  chief  drugs  employed.  In  the  lymphatic 
form,  arsenic  in  the  form  of  Fowler's  solution  gives  the  best  results, 
Hodgkins'  Disease  (Ance7nia  Lymphatica;  Adeniej  Pseudoleu- 
I'cpmia;  Lymphadenoma) . — This  disease  is  really  not  an  affection  of 
infancy  and  childhood  inasmuch  as  75  per  cent,  of  the  cases  occur 
above  the  age  of  ten  years.  It  is  mentioned  here  to  emphasize  its 
characteristics  as  distinct  from  tuberculous  adenitis  or  scrofulous 
enlargements  of  the  lymph-nodes.  It  is  an  affection  beginning  with 
the  enlargement  of  the  lymph-nodes  of  the  neck,  usually  of  one  side, 
and  accompanied  by  an  enlarged  spleen  and  liver.  In  the  spleen, 
liver,  and  other  organs  there  are  nodular  growths.  There  is  a  pro- 
gressive cachexia  accompanied  by  febrile  periods.  The  disease  is 
fatal  either  in  a  short  time  of  a  few  months  or  after  a  period  of  two 
or  three  years,  during  which  there  may  be  intervals  of  improvement. 
There  are  no  changes  in  the  blood  such  as  are  seen  in  true  leuksemia, 
and  in  this  lies  the  main  element  of  differential  diagnosis.  A  most 
complete  account  of  the  nature  of  this  rare  affection  will  be  found  in  a 
recent  monograph  by  Dr.  Reed,  published  in  the  Johns  Hopkins 
Hospital  Reports,  Vol.  X.,  and  in  a  monograph  by  Clarke  in  which 
he  collected  43  cases. 

The  Hemorrhagic  Diatheses. — In  this  class  of  diseases  are  em- 
braced only  those  affections  which  are  due  to  some  primary -change  in 
the  blood  or  in  the  circulatory  apparatus.  Thus  conditions  which  are 
due  to  local  disease  of  some  organ,  or  the  hemorrhages  which  follow 
the  acute  infectious  diseases  or  drug  poisoning  are  not  included. 
Experimental  pathology  has  as  yet  not  given  any  clue  to  the  etiology 
of  the  hemorrhagic  diatheses.  The  contention  of  William  Koch  and 
Ajello,  that  they  are  infectious  diseases  or  are  due  to  some  auto- 
intoxication, is  not  universally  accepted.  At  present  the  clinical 
classification  of  these  diatheses  into  the  transitory  forms  in  which  are 
included  purpura  simplex,  peliosis  rheumatica  hsemorrhagica,  scorbu- 
tus, and  the  persistent  form  hereditary  in  character,  such  as  ha?mo- 


748  LYMFH-NODES,  DUCTLESS  GLANDS  AND  BLOOD. 

philia,  may  be  accepted.  In  the  latter,  the  hemorrhage  may  be  exten- 
sive, difficult  to  control,  and  due  to  some  very  slight  cause. 

Simple  Purpura. — This  is  a  transitory  condition  characterized  by 
small  hemorrhages  or  petechise,  or  large,  irregularly  shaped  extrav- 
asations of  blood.  These  are  as  a  rule  discrete,  but  may  be  confluent, 
and  are  situated  in  the  epidermis  or  in  the  superficial  layers  of  the 
cutis.  Immediately  after  the  extravasation  the  hemorrhages  have  a 
bluish-purple  tinge.  After  a  few  days  they  become  brown  or  green- 
ish-yellow. These  extravasations  are  seen  most  frequently  on  the 
lower  extremities,  generally  on  the  extensor  surface.  They  also  occur 
in  other  localities. 

As  a  rule  there  are  few  or  no  symptoms.  There  may  be  crops  of 
petechise  appearing  at  short  intervals.  In  a  few  cases  there  are,  after 
an  exacerbation  of  the  local  phenomena,  loss  of  appetite,  vomiting, 
and  general  malaise.  The  so-called  purpura  cachecticorum  appears 
on  the  body,  abdomen,  back,  and  upper  extremities  in  children  under 
two  years,  suffering  from  diarrhoea  and  other  exhausting  diseases. 
In  the  latter  case  there  may  be  leucocytosis,  due  to  the  original  affec- 
tion. The  changes  in  the  blood  in  simple  purpura  are  still  to  be 
studied. 

Etiology. — The  cause  of  this  purpura  is  still  unknown.  It  may 
be  due  to  some  obscure  toxaemia. 

Prognosis. — The  prognosis  is  very  good  in  the  primary  form.  In 
the  secondary  form  it  will  depend  on  the  nature  of  the  original  affec- 
tion. 

Treatment. — The  treatment  will  depend  on  the  nature  of  the  origi- 
nal disease.  I  treat  the  purpura  itself  in  the  same  manner  as  cases 
of  purpura  h£emorrhagica,  which  will  later  be  fully  described. 

Haemophilia. — Hsemophilia  is  a  rare  condition  of  the  blood  and 
blood  tissues  which  may  be  congenital  or  hereditary.  It  becomes 
apparent  at  birth  or  in  early  infancy,  and  is  rare  in  later  life. 

Nature. — The  nature  of  the  affection  is  obscure.  It  is  a  type  of 
hemorrhagic  diathesis  which  is  transmitted  from  generation  to  gene- 
ration in  the  female  line.  It  is  characterized  by  the  occurrence  of 
uncontrollable  hemorrhage  after  very  slight  injuries,  and  operations, 
and  also  in  the  absence  of  known  traumatism. 

Etiology. — Many  theories  of  the  cause  of  the  affection  have  been 
advanced.    They  may  be  grouped  as  follows  : 

(a)  An  abnormal  delicacy  and  friability  of  the  bloodvessels. 

(b)  An  increase  of  the  volume  of  blood  (Immerman). 

(c)  A  defect  in  the  coagulable  constituents  of  the  blood. 

(d)  Certain  agencies  acting  as  toxins  on  the  elements  of  the 
blood,  causing  their  dissolution  (Koch). 

The  condition  is  most  common  in  the  Slavic  races.     Children 


PLATE   XXXIV 


Haemophilia.      Boy    six    years    of   age.      Haematoma    of   the    face ; 
hemorrhage  into  the  knee-joint.      (Case  of  Dr.  Martin  Ware.) 


DISEASES  OF  THE  BLOOD.  749 

dying  of  the  affection  show  evidences  of  intense  antemia,  but  may  be 
well  nourished.  Virchow  has  demonstrated  that  there  is  a  narrow- 
ness in  the  arteries  and  also  a  thinness  of  their  walls.  Birch-Hirsch- 
feld  found  that  the  endothelium  of  the  arteries  was  enlarged,  and  that 
the  nuclei  were  swollen.  The  blood  itself  shows  no  changes  except 
those  proper  to  post-hemorrhagic  anaemia. 

The  hemorrhages  may  occur  in  any  region  and  from  any  organ  of 
the  body.  There  may  be  hemorrhage  into  joints,  profuse  epistaxis, 
intestinal  hemorrhage  or  uncontrollable  hemorrhage  from  the  mouth 
or  lung.  The  drawing  of  a  tooth,  the  incision  of  an  abscess,  or  a 
minor  operation  such  as  circumcision,  may  cause  uncontrollable  and 
fatal  hemorrhage.  In  the  newly  born  infant,  there  may  be  fatal 
hemorrhage  from  the  cord.  In  the  case  pictured  in  Plate  XXXIV. 
there  were  hemorrhages  into  the  joints  and  into  the  face,  without 
distinct  traumatism.  This  case  came  of  a  family  of  bleeders  in  which 
there  had  been  fatalities  following  surgical  operations. 

The  condition  lasts  weeks,  months,  or  years — in  fact,  it  persists 
during  the  life  of  the  individual.  Some  authors  believe  that  the 
female  members  of  families  thus  affected  should  not  marry. 

Treatment. — The  treatment  is  mainly  prophylactic.  The  infant 
should  nurse  a  wet-nurse,  in  order  that  the  noxious  influence  of  its 
own  mother's  milk  may  be  lessened.  Good  food  and  fruits  of  all 
kinds  should  be  given.  All  operations  and  traumatism  should  be 
carefully  avoided. 

Purpura  Hsemorrhagica  {Morbus  Maculosus  Werlhofii). — In  the 
prodromal  period  before  the  appearance  of  the  hemorrhages,  there 
may  be  several  days  of  general  malaise,  disturbance  of  appetite  and 
digestion,  and  febrile  movement.  There  are  ansemia,  pain  in  the 
limbs,  and  oedema  of  the  feet.  The  hemorrhages  may  appear  without 
any  symptoms.  They  are  especially  frequent  in  the  lower  extremities, 
and  next  most  frequent  in  the  upper  extremities  and  on  the  chest, 
face,  and  trunk.  They  consist  of  extravasations  of  blood  in  the  skin 
and  subcutaneous  tissue.  The  mucous  membranes  are  frequently 
affected. 

Epistaxis,  bleeding  of  the  gums,  bloody  movements,  and  bloody 
urine  result.  There  are  ecchymoses  in  the  conjunctiva  and  bleeding 
from  the  ear.  The  hemorrhages  in  the  skin  may  be  petechise,  or 
irregular  bluish  or  purple  blotches  which  subsequently  become  yellow- 
ish or  greenish  yellow.  They  occur  spontaneously  or  follow  slight 
traumatism  or  pressure.  There  may  be  hemorrhages  into  the  joints. 
There  may  be  exacerbations  and  recurrences  of  hemorrhages  extend- 
ing over  weeks.  The  tendency  of  the  mucous  membrane  to  bleed  has 
been  mentioned.  The  gums  are  spongy  and  bleed  easily.  There  are 
hemorrhages  or  petechiae  on  the  soft  and  the  hard  palate.    The  hemor- 


750  LYMPH-XODES,  DUCTLESS  GLANDS  AND  BLOOD. 

rhages  from  the  kidney  cause  the  appearance  of  albumin  and  blood  in 
the  urine.  The  urine  is  red  and  blood-coloring  matter  may  be  found 
by  the  turpentine-guaiac  test.  Hemorrhages  in  the  brain  and  central 
nervous  system  may  occur,  causing  paralyses  and  coma.  In  mild 
cases  there  is  no  disturbance  of  nutrition,  but  in  severe  ones  the  • 
anaemia  is  marked,  as  is  also  the  emaciation.  The  blood  shows  few 
changes.  The  number  of  red  blood-cells  is  diminished,  as  is  also 
the  specific  gravity.  In  severe  cases  there  is  a  slight  leucocytosis ;  the 
polynuclear  leucocytes  are  increased,  eosinophiles  are  few,  microcytes 
are  present,  and  there  are  a  few  normoblasts.  The  leucocytosis  im- 
proves as  recovery  sets  in. 

Etiology. — The  etiology  of  this  affection  is  still  obscure.  Because 
of  its  infectious  nature,  William  Koch  believes  it  to  be  allied  to 
scorbutus  and  other  hemorrhagic  affections.  His  view  is  not  sup- 
ported by  other  writers.  Ajello  and  Schwab  regard  the  condition  as 
an  auto-infection  or  a  form  of  toxemia.  Kolb,  Tizzoni,  and  Babes 
have  found  bacteria  in  the  blood  of  fatal  cases.  Others  have  isolated 
streptococci  and  staphylococci  from  the  blood  (Lebreton).  In  one 
of  my  cases  there  was  a  history  of  an  insect-bite.  The  disease  is 
rare  in  breast-fed  infants  and  is  more  common  after  than  before  the 
age  of  two  years.  The  infants  and  children  attacked  may  have  pre- 
viously been  in  good  health. 

Diagnosis. — The  diagnosis  is  made  from  the  course  of  the  affection 
and  the  size  and  nature  of  the  hemorrhages.  The  constitutional  dis- 
turbance is  more  marked  than  in  simple  purpura.  The  hemorrhages 
are  blotchy,  in  that  respect  differing  from  the  petechia  of  peliosis. 
The  joints  are  not  swollen,  as  in  the  latter  affection. 

Prognosis. — The  cases  of  ordinary  severity  recover.  Severe  cases 
may  recover  or  may  result  fatally. 

Treatment. — The  treatment  consists  in  placing  the  patient  in 
hygienic  surroundings,  and  giving  a  nutritious  diet  with  a  liberal 
allowance  of  fruit  and  vegetable  acids.  In  marked  cases,  Fowler's 
solution,  given  in  moderate  doses,  gives  good  results. 

Purpura  Rheumatica  {Peliosis  Rheumatica  of  Schonlein)  .■ — Pur- 
pura rheumatica  consists  of  an  eruption  of  small  discrete  purpuric 
spots  in  the  vicinity  of  the  large  joints,  especially  of  the  lower  extrem- 
ities about  the  knee.  The  accompanying  symptoms  are  pain  and 
swelling  of  the  joints  of  the  lower  or  upper  extremities. 

Etiology. — The  etiology  is  obscure.  The  disease  occurs  in  children 
previously  healthy.  It  is  seen  in  older  children  only,  and  has  no 
apparrnt  relation  to  acute  articular  rheumatism. 

Symptoms. — Slight  fever  is  followed  by  tbe  appearance  of  the 
purpuric  spots  and  the  swelling  of  the  joints  of  the  lower  and  rarely 
of  the  upper  extremities.     The  joints  are  painful,  as  in  rheumatism. 


DISEASES  OF  THE  BLOOD.  751 

At  times  the  swelling  of  the  joints  is  less  apparent,  but  there  is 
nevertheless  tenderness  on  pressure.  The  purpuric  spots  are  partic- 
ularly numerous  in  the  vicinity  of  the  joints.  A  general  urticaria 
may  precede  the  appearance  of  the  purpura.  There  are  no  heart 
complications.  The  condition  of  the  blood  is  not  as  yet  understood. 
There  may  be  several  crops  of  purpuric  spots  appearing  at  intervals 
of  days  or  weeks.  In  other  cases  there  are  oedema  of  the  face  and 
enlargement  of  the  spleen.  In  one  of  my  cases  there  were  at  first 
slight  hemorrhages  from  the  bowel.  There  may  be  epigastric  pain 
and  tenderness  in  the  course  of  the  disease. 

The  average  duration  of  the  affection  is  from  ten  to  fourteen  days. 
There  may  be  relapses  extending  over  weeks. 

Prognosis. — The  prognosis  is  good  even  when  there  are  several 
relapses  and  when  the  affection  takes  a  subacute  course. 

Treatment. — Rest  in  bed  is  the  first  requisite  of  treatment.  The 
patient  is  put  on  a  nutritious  diet  in  which  there  is  an  abundant 
allowance  of  fruit  and  vegetable  acids.  Lemonade  and  orange-juice 
are  especially  indicated.  The  bowels  are  regulated  and  the  salicylate 
of  sodium  is  given  in  moderate  doses.  A  child  four  years  of  age  is 
given  grains  v  (0.3)  three  times  daily.  The  pains  in  the  joints  are 
easily  controlled  by  rest.  In  the  subacute  stage  small  doses  of 
Fowler's  solution  are  of  great  benefit. 

Henoch's  Purpura. — Henoch  in  1874  described  a  series  of  4  cases 
of  purpura  which  he  classified  as  distinct  from  purpura  hsemorrhagica 
or  poliosis  rheuniatica.  The  symptoms  were  as  follows:  Children 
in  apparent  good  health  were  attacked  by  a  form  of  purpura  in  which 
there  were  arthritic  pain,  vomiting,  and  intense  abdominal  pains  with 
bloody  diarrhoea.  The  rheumatoid  pains  were  accompanied  by  swell- 
ing of  the  joints.  The  purpura  was  of  the  hemorrhagic  type — that 
is  to  say,  there  were  extravasations  of  blood  in  the  form  of  ecchymoses 
or  raised  exanthematic  areas,  not  disappearing  on  pressure.  The 
areas  were  situated  on  the  abdomen  and  lower  extremities.  The 
joints  affected  were  those  of  the  wrist,  elbow,  and  ankle.  The  intesti- 
nal symptoms  consisted  of  repeated  vomiting,  tympanites,  excruciat- 
ing colicky  pains,  bloody  "stools,  and  tenesmus.  One  case  was  fatal. 
Such  cases  have  been  from  time  to  time  described  by  other  observers. 
I  have  seen  a  number  of  cases. 

These  cases  are  at  present  regarded  as  due  to  a  form  of  intestinal 
infection  the  exact  nature  of  which  is  still  obscure.  They  constitute 
a  group  probably  belonging  to  the  class  of  primary  hemorrhagic  affec- 
tions in  which  is  included  the  so-called  poliosis  rheumatica. 

Diagnosis  of  Forms  of  Purpura. — It  is  not  always  possible,  clinically, 
to  assign  each  form  of  purpura  to  its  proper  class.  This  is  especially 
true  with  young  children,  in  whom  there  occur  forms  of  purpura 


752  LYMPE-NODES,  DUCTLESS  GLANDS  AND  BLOOD. 

showing  a  diversity  of  symptoms  and  not  fitting  into  any  sharply 
defined  class.  ISTor  is  it  always  possible  at  the  bedside  to  decide 
whether  the  condition  present  is  scorbutus  or  idiopathic  purpura. 
Characteristic  of  both  purpura  and  scorbutus  are  the  hemorrhages 
into  the  skin,  the  internal  organs,  the  serous  cavities,  and  the  mucous 
membranes.  On  the  other  hand,  the  frequency  of  hemorrhages  and 
affections  of  the  giims,  the  prodromal  cachexia,  the  joint-affections, 
and  the  periosteal  hemorrhages  are  peculiarly  characteristic  of  that 
form  of  scurvy  called  Barlow's  disease,  which  is  seen  in  nurslings  and 
young  children.  The  purpuric  affections  of  so-called  idiopathic  type, 
in  which  a  purpuric  exanthema  is  spread  over  the  whole  surface,  may 
be  called  simple  purpura. 

In  the  so-called  rheumatic  purpura  or  poliosis  rheumatica  there 
is  a  blotchy  hemorrhagic  exudate  over  the  surface  in  the  vicinity  of 
the  joints,  with  pain  in  the  joints,  and  gastric  pains.  There  is  always 
a  tendency  to  relapses.  Hemorrhages  from  the  mucous  membranes 
and  bowels  are  rare,  but  occasionally  occur. 

In  purpura  hsemorrhagica  or  morbus  Werlhofii  there  are  minute 
or  blotchy  hemorrhages  in  the  skin  and  internal  hemorrhages  from 
the  mucous  membranes,  stomach,  and  intestines.  Attempts  to  define 
sharply  each  of  these  sets  of  cases  have  been  made.  It  is  not  always 
possible  or  desirable  to  do  so.  I  have  seen  cases  of  poliosis  with 
bowel  hemorrhages  and  gastric  crises,  and  cases  of  purpura  hsemor- 
rhagica  in  infants,  in  which  there  were  pains  in  the  joints,  evinced 
by  the  distress  shown  when  the  joints  were  moved.  The  forms  of 
purpura  regarded  by  Henoch  as  a  distinct  type  are  classed  by  others 
as  purpura  rheumatica.  The  different  classes  of  idiopathic  purpura 
therefore  overlap,  one  case  frequently  showing  symptoms  of  two  types. 
The  only  possible  conclusion  is  that  there  may  be  a  common  cause 
of  all  forms  of  purpura — probably  an  infection. 

Pernicious  Anaemia. — This  is  a  primary  anaemia  which  causes 
progressive  impoverishment  of  the  blood  and  results  in  death.  It  is 
not  common  in  infancy  and  childhood.  The  condition  of  the  blood  in 
pernicious  anaemia  in  infancy  and  childhood  has  not  as  yet  been 
closely  studied.  The  changes  in  the  blood  which  have  been  published 
as  characteristic  of  this  condition  in  infancy  and  childhood  are  found 
in  other  states,  such  as  the  severe  anaemia  of  rachitis  and  syphilis. 
Ehrlich  is  not  disposed  to  accept  these  cases  without  question.  Blood 
pictures  which  in  the  adult  may  be  diagnostic  of  pernicious  anaemia 
cannot  be  thus  interpreted  when  found  in  infants  and  young  children. 
Observers  of  note,  such  as  Monti,  Berggrlin,  and  Baginsky,  have  pub- 
lished cases  in  infants  and  young  children.  I  have  met  a  case  in  an 
infant  which  had  been  bitten  by  a  rat.  After  an  interval,  anaemia 
of  a  progressive  and  fatal  type  set  in.     The  changes  in  the  blood  were 


DISEASES  OF  THE  SUPBAEENAL  BODIES.  753 

similar  to  those  characteristic  of  the  same  form  of  ansemia  in  the 
adult.  Monti  has  collected  16  cases,  2  of  which  were  in  infants;  5 
ranged  from  one  to  six  years ;  9  were  above  the  age  of  five  years.  On 
the  other  hand,  Ehrlich  found  that  of  240  authentic  cases,  only  1 
occurred  in  the  first  decade  of  life.  That  case  was  in  a  girl  of  eight 
years.  In  the  face  of  such  great  diversity  of  opinion,  it  is  wise  to 
await  the  results  of  further  research.  For  the  purpose  of  reference, 
the  following  account  of  the  changes  in  the  blood  which,  according  to 
Ehrlich,  are  diagnostic  of  pernicious  ansemia  in  the  adult,  is  ap- 
pended : 

(a.)    The  volume  of  blood  is  markedly  diminished. 

(&)  The  color  is  at  first  normal,  but  later  resembles  that  of  beef- 
water. 

(c)  The  haemoglobin  may  be  as  low  as  10  per  cent.  (Fleischl). 
This  is  due  to  a  diminution  of  the  number  of  red  blood-cells,  for  the 
individual  cell  may  have  a  hjemoglobin  content  equal  to  the  normal 
or  above  it. 

(d)  There  are  microcytes,  megalocytes,  and  sometimes  giganto- 
cytes.  The  megalocytes  may  constitute  70  per  cent,  of  the  red  blood- 
cells.  They  become  fewer  on  convalescence.  There  are  few  megalo- 
blasts,  but  characterictic  normoblasts  are  found. 

(e)  Clumps  of  free  granules  are  found  in  the  blood.  The  red 
blood-cells  may  contain  granules. 

(/)    Staining  solutions  produce  polychromatophilic  effects. 

(g)   The  eosinophiles  are  normal  in  number. 

(h)  The  number  of  white  blood-cells  is  diminished  as  well  as 
that  of  the  polynuclear  neutrophiles.  The  latter  condition  indicates 
serious  involvement  of  the  bone-marrow.  The  lymphocytes  are 
proportionately  increased. 

(^)  The  leucocytes  show  no  changes.  Improvement  is  ushered 
in  by  leucocytosis. 

(j)  The  specific  gravity  of  the  blood  is  diminished,  as  is  also  its 
coagulability. 

In  my  case  the  nucleated  red  blood-cells  were  numerous. 

DISEASE  OF  THE  SUPRARENAL  BODIES. 

Addison's  Disease  (Morbus  Addisonii) . — This  is  an  exceedingly 
rare  aifeetion  before  the  tenth  year  of  life.  Of  48  cases  collected  by 
Dezirot,  only  6  occurred  before  the  tenth  year.  Most  of  the  cases  col- 
lected by  this  author  (in  children)  occurred  before  the  twelfth  and 
fifteenth  years.  It  may  occur  in  the  newborn.  It  is  caused  by  tuber- 
culous degeneration  of  the  suprarenal  capsule,  although  in  one  case 
there  was  carinoma  of  this  organ.    Apart  from  asthenia  and  melano- 

48 


754  LYMPH-NODES,  DUCTLESS  GLANDS  AND  BLOOD. 

dermie,  gastro-intestinal  disturbances  and  convulsions  dominate  the 
development  of  the  disease.  Vomiting  is  very  frequent.  The  con- 
junctiva and  nails  escape  pigmentation. 

The  duration  is  shorter  and  the  disease  more  rapidly  fatal  in 
children  than  in  adults.  Sudden  death  is  a  frequent  termination. 
Enlargement  of  the  mesenteric  lymph-nodes  and  Peyer's  patches  ^nd 
solitary  follicles  have  been  observed.  The  pigmentation  of  the  buccal 
and  other  mucous  membranes  remain,  as  in  the  adult,  pathognomonic 
of  the  disease.  It  must  be  differentiated  from  tuberculosis  of  the 
peritoneum  with  melanodermie  and  gastro-intestinal  crises.  Pigmen- 
tation, however,  of  the  mucous  membranes  remains  characteristic  of 
Addison's  disease. 

Treatment. — Inasmuch  as  the  operative  treatment  in  adults  has 
in  certain  cases  caused  an  amelioration  of  the  symj)toms,  it  might 
also  be  tried,  if  the  diagnosis  is  certain,  in  children. 


SECTION  XII. 

DISEASES  OF  THE  BONES. 

General  Considerations.^ — In  examining  the  joints,  it  should  he 
borne  in  mind  that  the  bones  entering  into  the  formation  of  the  joints 
may  be  affected.  The  diaphysis  may  be  diseased  without  accompany- 
ing involvement  of  the  joint. 

Tuberculosis. — In  all  bone  lesions  tuberculosis  should  be  excluded. 
In  infants  and  children,  the  question  as  to  whether  the  existing  con- 
dition is  tuberculosis  of  the  bone  or  syphilis  is  constantly  arising. 

Syphilis  affects  by  predilection  the  long  bones  in  the  diaphysis, 
while  tubercle  affects  the  short  bones,  especially  in  the  vicinity  of  the 
joints.  In  this  region,  also,  tubercle  attacks  the  epiphyses  of  the  bone 
and  may  thus  involve  the  joints  secondarily. 

Pain  in  syphilitic  bone  lesions  is  very  marked,  acute,  and  with 
nocturnal  exacerbations;  while  the  pain  of  tubercular  bone  lesions 
is  obseure  and  indefinite,  although  persistent. 

The  swelling  in  syphilis  is  in  the  form  of  a  periostitis  or  an  ostitis 
involving  only  the  bone ;  in  tuberculosis,  the  surrounding  tissues  are 
affected  as  well  as  the  bone,  and  abscess  and  fungous  granulation 
result. 

Syphilis  rarely  suppurates ;  the  contrary  is  true  of  tuberculosis. 

Syphilis  of  the  bones  does  not  as  a  rule  lead  to  cachexia ;  tuber- 
culosis of  the  bone  eventually  causes  cachexia  and  emaciation. 

There  are  cases  in  which  doubt  will  arise  as  to  the  true  nature  of 
the  bone  affection.  This  is  especially  the  case  when  the  small  bones 
of  the  hand  are  affected.  In  such  cases  a  tuberculin  test  is  indicated. 
'  Sudden  painful  swelling  of  the  long  bones  occurring  in  corre- 
sponding bones  on  both  sides  should  awaken  a  suspicion  of  syphilis, 
even  in  the  absence  of  other  signs  of  syphilitic  disease.  A  long  bone 
which  has  been  affected  by  syphilis  will  be  irregularly  thickened, 
owing  to  the  repeated  attacks  of  periostitis.  This  thickening  is  likely 
to  be  confounded  with  that  caused  by  rachitis. 

In  rachitis,  the  bone  is  less  painful  than  in  syphilis  and  the 
thickening  is  invariably  uniform  and  smooth.  In  scurvy  there 
may  be  a  thickening  of  the  long  bones  due  to  hemorrhage  in  the 
periosteum.  In  these  cases  the  history  and  also  the  presence  of  other 
signs  of  scorbutus,  such  as  hemorrhages  in  the  skin  or  bleeding  of 
the  gums,  will  aid  diagnosis. 

755 


756  DISEASES  OF  THE  BOXES. 

Craniotabes. — In  locating  patches  of  so-called  craniotabes,  the 
surface  of  the  occipital  and  other  hones  of  the  skull  is  examined  for 
deficiency  of  hone  formation.  The  occipital  bone  will  in  rachitis 
present  membranous  spots  more  frequently  than  is  generally  sup- 
posed. The  most  common  tumors  found  on  the  scalp  are  those  due  to 
traumatism  at  birth,  such  as  cephaloha?matoma,  tumor  of  the  scalp 
with  depressed  bone,  and  tumor  due  to  syphilis.  The  cephaloheema- 
toma  is  found  after  birth  and  need  not  be  described  here.  If  an 
infant  falls  on  one  side  of  the  head  from  a  height,  a  depression  of  the 
skull  may  at  once  take  place.  This  occurs  if  the  bones  are  soft  and 
not  yet  completely  ossified.  The  depression  is  filled  with  an  effusion 
of  blood  and  serum.  A  soft  tumor  results  which  may  not  project 
above  the  surface  at  all  or  only  slightly  so.  Around  the  border  of  the 
tumor  the  rim  of  bone  bordering  the  depression  can  be  felt.  In  this 
respect  the  condition  differs  from  the  cephalic  hsematoma  found  after 
birth.  In  the  latter,  the  whole  tumor  is  raised  from  the  surface,  and 
on  physical  examination  there  are  no  evidences  of  depression. 

Sypiilis. — Syphilis  (Fig.  92)  may  cause  the  formation  of  tumors 
on  the  surface  of  the  frontal  and  parietal  bones  varying  from  the  size 
of  a  hazelnut  to  that  of  a  walnut.  They  may  at  first  be  hard  and 
subsequently  soften.  They  resemble  abscesses,  and  should  be  differ- 
entiated from  them.  Tuberculosis  of  the  bones  may  also  cause  such 
tumors.  Tuberculosis  of  the  skull  bones  in  infancy  is  of  rarer  occur- 
rence than  syphilis  of  the  skull,  the  cases  of  mastoid  disease  being 
excepted.  In  a  concrete  case,  syphilis  should  be  assumed  until  it  can 
be  excluded.  The  difficulties  of  diagnosis  may  be  cleared  by  a  tuber- 
culin test.  Abscess  may  be  diagnosed  if  there  are  abscesses  elsewhere 
in  the  body.  This  is  the  case  in  folliculitis  abscedens  of  Escherich. 
Mistakes  rarely  occur  in  these  cases,  since  all  the  sigTis  of  abscess  are 
present. 

Acute  Infectious  Osteomyelitis.- — Osteomyelitis  is  an  acute  in- 
fectious inflammation  of  the  structure  of  the  bones.  It  is  common  in 
infancy  and  childhood.  Of  50  cases  below  the  thirteenth  year  col- 
lected by  Blumenfeld,  50  per  cent,  were  under  five  years  of  age. 
The  sexes  were  equally  affected. 

Etiology." — In  the  majority  of  cases  the  essential  cause  is  the 
Staphylococcus  pyogenes  aureus.  The  disease  may,  however,  be 
caused  by  any  pyogenic  micro-organism,  such  as  the  Streptococcus 
pyogenes,  the  pneumococcus,  the  Bacillus  typhosus,  the  Recurrens 
spirillum,  Bacterium  coli,  and  the  gonococcus.  Of  90  cases  collected 
and  reported  by  Lannr longue,  only  10  were  due  to  the  streptococcus. 
Launelongue  and  Achard  were  the  first  to  show  that  osteomyelitis  may 
be  caused  by  streptococci  in  1890.  Van  Arsdale  and  the  writer,  in 
1891 ,  published  4  cases  of  osteomyelitis  caused  by  streptococci.      These 


DISEASES  OF  THE  BONES.  757 

occurred  in  newborn  infants  or  followed  scarlet  fever  and  pneumonia. 
The  streptococcus  osteomyelitis  is  of  especial  interest  to  the  physician, 
as  it  occurs  in  infants  and  children  under  two  years  of  age.  It  fre- 
quently follows  infection  of  the  umbilicus  in  the  newborn  infant,  the 
exanthemata  (scarlet  fever  and  measles),  and  pneumonia.  It  differs 
from  the  staphylococcus  variety  in  that  the  inflammation  of  the  bone 
is  less  likely  to  involve  the  medullary  canal,  but  affects  the  epiphysis. 
There  is  also  involvement  of  the  joints,  with  suppuration.  The 
bacteria  gain  access  to  the  circulation  (Garre),  and  to  the  bones 
through  some  wound,  such  as  the  umbilicus ;  through  the  mucous 
membranes,  as  in  ulcerations  of  the  mouth ;  through  some  lesions  of 
the  skin,  such  as  an  eczema  or  furuncle,  or  through  the  gut.  Of  the 
47  cases  cited  above,  17  were  due  to  trauma,  and  5  followed  infectious 
diseases.  The  causative  bacteria  are  found  in  the  joints  and  in  cases 
of  sepsis  in  the  blood. 

Pfisterer  has  recently  published  7  cases  of  arthritis  caused  by  the 
pneumococcus.  In  most  of  these  cases  the  disease  was  monarticular; 
though  in  one  case  several  joints  were  involved.  The  arthritis  of 
this  variety  for  the  most  part  involves  the  larger  joints.  The  symp- 
toms are  similar  to  the  streptococcus  form,  and  yield  kindly  to  treat- 
ment. Some  of  the  cases  may  complicate  a  pneumonia,  or  they  may 
also  occur  independently  of  this  disease.  If  complicating  a  pneu- 
monia, the  affection  may  appear  from  the  first  to  the  ninth  week  of 
convalescence. 

Morbid  Anatomy. — The  seat  of  inflammation  is  the  periosteum  and 
the  medullary  substance  of  the  bone  chiefly.  The  inflammation  of 
the  marrow  and  spongy  part  of  the  bone  involving  the  cortical  bone 
layer  is  often  spoken  of  as  osteitis,  that  of  the  periosteum  as  periosti- 
tis. There  is  a  primary  form  and  one  secondary  to  infections  else- 
where in  the  body.  It  is  a  disease  of  young  people  and  involves 
mostly  the  long  bones.  The  periosteum  is  swollen,  hyperasmic,  the 
seat  of  hemorrhages  and  finally  of  purulent  infiltration.  The  bone 
marrow  and  neighboring  bone  tissue  is  hypersemic,  the  seat  of  hem- 
orrhages, and  after  a  time  purulent  infiltration.  The  whole  marrow 
canal  may  be  converted  into  a  pus  cavity,  and  pus  may  form  under- 
neath the  periosteum.  The  bone  tissue  becomes  infiltrated  with  pus, 
breaks  down  and  forms  sequestra.  Abscesses  may  form  in  the  bone. 
In  the  subsequent  history  of  the  separation  of  the  diseased  from  the 
healthy  bone  the  processes  are  those  seen  in  all  bone  inflammations. 

Symptoms. — In  older  children,  the  symptoms  differ  little  from 
those  of  the  adult  subject.  The  femur  and  tibia  are  most  commonly 
involved ;  next  the  humerus,  superior  maxilla,  inferior  maxilla,  ileum, 
and  radius,  in  the  order  named.  In  some  cases  the  onset  is  sudden 
and  the  fatal  issue  takes  place  in  a  few  days.     In  others,  the  inva- 


758  DISEASES  OF  TEE  BONES. 

sion  is  gTadual.  lu  older  children  there  are  the  regular  symptoms 
of  chill,  fever,  and  vomiting,  followed  by  local  symptoms. 

In  young  infants  the  signs  of  osteomyelitis  are  obscure.  In  the 
puerperal  cases  in  newborn  infants,  the  umbilicus  may  be  inflamed 
for  some  days,  after  which  the  infant  begins  to  cry  when  handled  in 
the  bath.  The  umbilicus  may  be  healed  and  the  symptoms  referable 
to  the  joints  may  not  appear  until  weeks  after  birth.  One  extremity  is 
not  moved  and  a  joint  may  be  swollen  (Plate  VII.) .  Swelling  of  the 
joint  may  escape  notice  until  the  child  is  examined  by  the  physician. 
After  scarlet  fever,  the  swelling  of  the  joints  is  quite  apparent,  and 
also  after  pneumonia.  In  the  newborn  infant  several  joints  may  be 
swollen.  In  one  of  my  cases  in  an  infant  ten  months  old,  the  elbow- 
joint  and  wrist-joint  were  involved,  the  whole  radius  being  the  seat 
of  osteomyelitis.  Similar  cases  have  been  published  in  this  country 
by  Gibney.  The  frequency  of  joint-involvement  is  a  feature  of 
osteomyelitis  in  children.  Of  50  cases  of  osteomyelitis  published  by 
Blumenfeld,  the  joints  were  involved  in  30.  I  have  seen  the  multiple 
joint-suppurations  most  frequently  in  newborn  infants.  In  all  cases, 
there  are  evident  swelling  of  the  tissues  about  the  joints  and  fluctua- 
tion in  the  joint-cavity.     The  joint  contains  pus. 

Bacteria  are  found  in  the  pus  and  in  the  blood.  In  the  newborn 
a  meningitis  of  the  same  bacterial  nature  as  that  of  the  joints  may 
close  the  symptomatology. 

Diagnosis. — The  diagnosis  is  not  difiicult.  If  an  infant  cries  when 
it  is  handled,  every  joint  should  be  carefully  examined.  Osteomyeli- 
tis may  be  confounded  with  scorbutus.  In  the  latter  affection,  the 
joints  are  painful  and  swollen,  but  do  not  contain  fluid.  In  scorbutus 
there  are  ecchymoses,  swelling  and  sponginess  of  the  gums,  and 
hemorrhagic  lesions  underneath  the  skin,  all  of  which  will  aid  in 
diagnosis.  A  history  of  umbilical  inflammation  or  of  scarlet  fever 
is  of  great  value.  There  are  in  congenital  syphilis  of  young  infants 
forms  of  inflammation  about  the  joints  which  at  flrst  simulate 
osteomyelitis.  In  such  cases  the  infant  should  be  examined  for  other 
evidences  of  congenital  syphilis,  such  as  fissures  and  rhagades  about  the 
mouth  and  anus,  mucous  patches,  and  coppery  discolorations  of  the  skin. 
Tuberculous  inflammation  in  the  long  bones  or  in  the  heads  of  the 
l)ones  may  present  some  difiiculties  of  diagnosis.  A  study  of  the  case 
and  the  absence  of  a  history  of  acute  trouble  will  solve  the  difficulty. 

Prognosis. — The  prognosis  of  acute  osteomyelitis  in  newly  born 
infants  is  grave.  The  majority  of  cases  are  fatal  owing  to  the  form- 
ation of  multiple  foci  of  suppuration.  The  prognosis  is  also  grave  in 
infants  under  one  year  of  age.  The  mortality  of  all  cases  under  the 
fifth  year  is  50  per  cent.     In  oldtr  diildrcn  it  is  20  per  cent. 

Treatment.-  Ilic  li-eatnicut  of  acute  infectious  osteomyelitis  is 
surgical. 


SECTION  XIII. 

DISEASES  OF  THE  EAR. 

Otitis  in  Infancy  and  Childhood. — Frequency. — Otitis  media,  ca- 
tarrhal or  purulent,  is  a  very  conimou  disease  of  iufancv  and  child- 
hood. It  is,  as  a  rule,  a  secondary  aflection,  but  may  in  rare  cases 
occur  as  a  primary  disease.  Parrot  first  called  attention  to  the  fre- 
quency of  otitis  as  a  complication  of  bronchopneumonia,  i^ettermade 
the  first  bacteriological  examinations  of  the  discharges  from  the  ear. 
The  subjects  were  20  children  whose  ages  ranged  from  nine  days  to 
two  years.  Kossel,  Easch,  and  Ponfick  have  investigated  the  fre- 
quency and  nature  of  this  affection  in  children.  The  results  of  their 
work  show  striking  uniformity.  Fully  85  per  cent,  of  infants  and 
children,  examined  post  mortem,  were  found  to  have  diseased  ears. 
Most  of  the  infants,  especially  those  examined  by  Ponfick,  had  died 
of  gastro-enteritis,  acute  or  chronic.  Some  had  suffered  from  gastro- 
enteritis, pneumonia,  or  congenital  syphilis. 

Etiology. — The  etiology  of  acute  catarrhal,  acute  suppurative  otitis 
media  and  of  acute  suppurative  mastoiditis  is  much  the  same.  The 
naso-pharynx  and  the  Eustachian  tube  are  normally  the  habitat  of 
various  forms  of  bacteria.  This  is  the  case  in  infants  and  children 
who  have  enlarged  tonsils  and  adenoid  gTOwths.  A  reduction  of  the 
vitality  of  the  individual  or  any  acute  disease  favors  invasion  of  the 
ear  by  bacteria  entering  the  Eustachian  tube.  Thus  the  exanthemata, 
especially  scarlet  fever  and  measles,  furnish  a  large  quota  of  cases. 
Diphtheria,  typhoid  fever,  typhus  fever,  varicella,  influenza,  gastro- 
enteritis, tonsillitis,  and  simple  angina,  also  cause  a  large  number  of 
cases  of  otitis.  Pertussis,  cerebK)spinal  meningitis,  and  pneumonia 
are  complicated  by  the  disease.  Sea-bathing,  exposure  to  cold,  and 
nasal  douching  favor  its  onset. 

Bacteriology. — The  bacteria  found  by  different  observers  in  the 
otitic  discharges  and  in  the  cavities  of  the  ear  include  the  Staphy- 
lococcus pyogenes  aureus,  citreus,  and  albus,  the  Streptococcus  pyo- 
genes, the  pneumococcus  of  Frankel.  the  influenza  bacillus  and 
pseudo-influenza  bacillus,  the  Bacillus  foetidus,  and  the  Bacillus  pyo- 
cyaneus  (N^etter,  Kossel,  Ponfick).  The  streptococci  and  influenza 
bacilli  cause  an  especially  severe  inflammation,  the  pneumococcus  a 
milder  form.     The  diphtheria  bacillus  also  causes  otitis. 

Morbid  Anatomy. — In  both  forms  of  otitis  and  also  in  mastoid 
disease  the  tympanic  membrane  is  injected  and  the  vessels  at  its 

759 


760  DISEASES  OF  THE  EAE. 

border  are  increased  in  size.  The  vessels  of  the  hammer  are  injected. 
The  epidermis  of  the  tympanic  membrane  may  be  intact.  The  tym- 
panic cavity  may  be  filled  with  cellular  elements.  There  may  be  a 
serous,  mucous,  purulent,  or  mucopurulent  exudate.  The  mucous 
membrane  of  the  tympanic  cavity  may  be  intact  but  injected,  or  may 
shovr  gross  defects.  If  the  bony  structures  are  involved,  there  v^^ill  be 
necrosis  of  bone,  especially  of  the  tegmen  tympani.  There  may  be 
perforation  of  this  structure  or  of  the  point  of  the  mastoid  process. 
The  dura  mater  or  sinuses  of  the  dura  may,  in  progressive  mastoid, 
be  inflamed.  T/iere  may  be  cerebral  abscess.  If  the  pus  does  not 
escape  by  way  of  the  Eustachian  tube,  it  may  perforate  the  tym- 
panum. The  exudate  which  fills  the  tjanpanic  cavity  contains  epi- 
thelial cells,  leucocytes,  and  blood-cells. 

Otitis  Media  Catarrhalis. — Acute  catarrhal  otitis  is,  in  a  vast  num- 
ber of  cases,  simply  a  forerunner  of  otitis  media  purulenta  or  of  an 
acute  suppurative  otitis.  It  will  be  couA-enient  for  the  practitioner 
to  consider  these  affections  together. 

They  are  more  common  among  infants  and  children  than  among 
adults,  and  may  occur  at  the  earliest  period  of  infancy.  They  occur 
most  frequently  in  the  spring  and  summer. 

The  causation  has  been  considered  under  the  etiology,  and  is  the 
same  in  both  affections. 

Symptomatology. — In  young  infants  and  in  children  under  two 
years  of  age,  the  symptoms  are  frequently  masked  by  those  of  the 
primary  disease.  In  many  cases,  the  otitis  gives  no  special  warning 
of  its  presence.  Perforation  of  the  drum  and  a  purulent  discharge  are 
the  first  intimation  of  the  condition.  This  is  especially  the  case  in 
otitis  in  young  nurslings  who  have  suffered  from  acute  tonsilitis  or 
pneumonia,  but  these  are  not  the  cases  which  the  practitioner  is  called 
upon  to  diagnose. 

In  another  set  of  cases,  especially  in  those  in  which  otitis  is 
coincident  with  gastro-intestinal  disorders  of  a  chronic  type,  tending 
to  atrophy,  Heermann  and  Ponfick  have  shown  that  during  life  the 
otitis  gives  no  objective  symptoms  although  on  otoscopic  examination 
the  tympanic  cavity  is  found  to  be  filled  with  pus,  so-called  marantic 
cases.  In  cases  which  follow  the  milder  types  of  influenza  or  angina, 
there  may  be  a  most  puzzling  set  of  symptoms  which  can  only  be 
referred  to  the  ear.  In  these  cases  the  physician  finds,  two  or  three 
days  after  the  onset  of  tonsillitis  or  influenza,  that  the  temperature 
does  not  drop  to  the  normal;  it  may  mount  to  104°  F.  (40°  C.) 
toward  evening,  and  in  the  morning  may  drop  to  or  within  a  degree 
of  the  normal.  While  the  temperature  is  low  the  infant  takes  its 
food  and  plays.  When  it  rises  the  infant  becomes  fretful,  or  stupid, 
or  sleeps  most  of  the  time.     There  is  no  iiiflication  of  pain. 


OTITIS  IN  INFANCY  AND  CHILDHOOD. 


761 


In  other  cases  the  infants  will  start  from  sleep  and  cry  with  pain. 
In  some  cases  the  infants  perspire  freely  at  the  falling  of  the  temper- 
ature. These  simulate  in  many  respects  cases  of  malaria  or  of 
meningitis  of  the  tuberculous  type,  except  that  the  temperature  rises 
higher  than  in  the  latter  disease  (Fig.  172).  Local  facial  pareses 
may  complete  the  resemblance  to  meningitis.  The  intermittent  or 
recurrent  curve  of  temperature  may  continue  for  a  week  or  ten  days. 
Only  the  careful  exclusion  of  disease  of  other  organs,  and  especially 
of  the  lungs  and  of  the  heart,  will  lead  the  physician  to  suspect  disease 
of  the  ear.  In  nursing  infants  the  bowels  will  be  abnormal  and  the 
movements  greenish,  containing  white  curds.  The  temperature  is, 
however,  much  higher  than  in  any  diarrhoea,  and  is  more  persistent 
and  regular  in  its  daily  fluctuations. 


Fig.  17 

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Otitis  media  purulenta  in  a  child  eighteen  months  of  age.      Symptoms  and  curve  simu- 
lating closely  a  meningitis  of  the  basal  type. 


In  cases  of  broncho-pneumonia  complicated  with  otitis,  previous 
to  the  spontaneous  perforation  of  the  drum  the  temperature  will  have 
shown  more  decided  fluctuations  than  would  occur  at  a  late  stage  of 
the  primary  disease.  However,  in  pneumonia  there  are  few  or  no 
objective  signs  of  the  affection.  Older  children  may  have  certain 
definite  symptoms  such  as  dull  headache  and  pain  in  the  ear,  which, 
if  sharp  and  stinging,  will  cause  them  to  start  in  sleep,  or  to  awake 
and  cry  out  or  put  the  hand  to  the  ear.  This  last  sign,  so  often  men- 
tioned in  the  text-books,  I  have  seldom  seen.  There  may  be  delirium 
and  the  fever  may  be  quite  high.  Children  who  can  talk  complain 
of  pain  at  night.  There  may  be  rushing,  singing,  or  buzzing  noises 
in  the  ear.  Very  characteristic  is  the  starting  of  infants  during 
sleep.    Older  children  are  out  of  sorts,  and  angry  on  awakening. 

Course. — Spontaneous  perforation  in  a  number  of  cases  occurs 
in  a  few  hours  or  a  few  days  after  the  onset  of  the  disease.  As  a 
rule,  however,  pain  continues  with  fever  until  artificial  paracentesis 
of  the  drum  is  practised.  After  spontaneous  rupture  of  the  tympa- 
num, or  paracentesis,  the  discharge  may  continue,  being  in  some  cases 
serous  or  serosanguinolent,  and  later  becoming  purulent.  The  puru- 
lent discharge  may  be  profuse  and  the  disease  may  advance  into  the 


762 


DISEASES  OF  THE  EAB. 


mastoid  or  labyrintli.  This  frequently  occurs  in  cases  of  tlie  ex- 
anthemata or  in  pneumonia  or  influenza.  In  severe  cases,  the 
discharge  may  continue  and  become  chronic,  resulting  in  destruction 
of  the  structures  of  the  ear.  Complications  may  intervene,  such  as 
facial  erysipelas,  meningitis,  cerebral  abscess,  thrombosis  of  the 
cerebral  sinuses,  and  finally  in  suppurative  cases  pyiemia  may  inter- 
vene. On  the  other  hand,  after  spontaneous  rupture  or  paracentesis 
of  one  or  both  drums,  the  serous  or  purulent  discharge  may  gradually 
cease  and  the  ears  be  restored  without  any  defect  of  hearing.  In 
many  cases  incision  of  the  drum  in  the  early  stages  of  the  disease  is 
not  followed  by  the  discharge  of  pus;  the  symptoms  cease,  and  the 

riG.  173. 


Examination    of   the    ear    with    head   minor    and    reflector. 


patient  recovers.  In  other  cases  there  is  no  rupture  of  the  tym- 
panum, although  the  tympanic  cavity  is  filled  with  exudate,  which 
discharges  through  the  Eustachian  tube.  The  pus  may  be  swallowed 
and  cause  diarrhoea  or  pneumonia.  In  the  cases  of  marasmus  with 
otitis  descril)ed  by  Hecrmann,  the  pus  is  believed  to  have  found  its 
way  from  the  middle  ear  through  the  tube  to  the  naso]>harpix. 

Method  of  Examination  of  the  Ear  in  Infants  and  Children. — The 
examination  of  these  young  ])atients  must  often  be  made  at  the  bed- 
side, where  the  examiner  does  not  have  all  the  conveniences  of  the 
ofRce  equipment,  so  that  he  should  be  prepared  for  the  use  of  the 
head-mirror  with  the  light  from  a  candle  or  a  kerosene  lamp  which  is 
still  better. 

If  the  examiner  is  mvoi)ic,  this  is  in  his  favor,  but  if  he  has 


OTITIS  IN  INFANCY  AND  CHILDHOOD. 


763 


liypermetropia  or  is  presbyopic,  the  necessary  correcting  glasses 
should  be  worn,  for  without  good  vision  for  the  near-point,  it  will  be 
difficult  to  make  out  any  details. 

If  there  are  no  contra-indications  such  as  weak  cardiac  action, 
the  young  patient  should  be  placed  in  an  upright  position  on  the  lap 
of  an  assistant  and  the  entire  body  from  the  neck  downwards  should 
be  wrapped  in  a  blanket  or  sheet,  with  the  arms  down  and  fully 
extended  alongside  of  the  body  (Fig.  173). 

Fig.  174. 


Examination   of   the   ear   witli   the   electric   headlight. 

The  assistant  holding  the  child  should  be  seated  on  a  firm  chair 
with  a  back.  In  the  examination  of  the  right  ear,  the  assistant 
presses  the  back  of  the  child's  head  against  the  chest,  by  holding  the 
patient's  forehead  with  the  left  hand,  and  for  the  left  ear,  vice  versa, 
— care  being  taken  that  the  other  arm  firmly  encircles  the  child's 
body  and  arms. 

If  the  electric  head-light  is  used,  or  the  electro-otoscope  or  a 
nearby  gas  or  electric  light,  no  further  assistance  will  be  required, 
but  if  a  candle  or  kerosene  lamp  is  brought  into  requisition,  a  third 
party  may  be  needed  to  hold  the  light  a  little  above  and  behind  the 
patient's  head  (Fig.  174). 

Furunculosis  and  impacted  cerumen  are  very  infrequent  among 
children,  but  foreign  bodies  such  as  peas  and  pebbles  and  small 
insects  must  be  considered  as  likely  to  obstruct  vision. 


764  DISEASES  OF  THE  EAR. 

One  of  the  greatest  obstacles  to  a  proper  examination  of  the  mem- 
hrana  tympani  in  children  is  the  presence  of  exfoliated  epithelium 
which  is  often  pnli^y  in  consistence  and  covers  the  external  surface  of 
the  membrana  tvmpani  in  a  thin  layer,  thereby  hiding  the  details  of 
its  appearance. 

The  presence  of  this  deposit  indicates  an  inflammation  of  the 
tympanum  often  only  of  a  sub-acute  type,  but  which  has  been  present 
for  some  days.  The  removal  of  this  deposit  by  irrigation  with  a 
warm  borax  solution  will  reveal  the  surface  of  the  tympanum. 

In  selecting  a  speculum  one  should  be  chosen  which  does  not  crowd 
the  canal,  as  this  is  also  apt  to  give  unnecessary  pain,  and  when 
introduced,  it  should  be  inserted  by  a  revolving  motion.  It  must  be 
remembered  that  the  plane  of  the  drum-head  lies  more  horizontal  in 
the  young  than  the  older  subject,  and  in  making  traction  upon  the 
auricle,  one  should  make  traction  somewhat  downwards  and  back- 
wards, instead  of  upwards  and  backwards  as  in  older  subjects. 

In  cases  where  there  are  large  sub-  or  retro-maxillary  glands,  the 
floor  of  the  canal  may  have  been  pushed  upwards  so  that  it  is  some- 
times almost  impossible  to  see  the  fundus  of  the  canal  even  with  the 
smallest  speculum.  In  such  cases  it  is  best  to  pack  a  little  strip  of 
gauze  into  the  canal  for  a  few  hours,  and  upon  its  removal  the  canal 
will  be  sufficiently  dilated  to  permit  of  the  introduction  of  a  speculum. 
In  all  cases,  both  ears  should  be  examined,  even  though  we  have 
manifest  evidence  of  disease  in  one  ear  only. 

Diagnosis. — The  diagnosis  is  first  made  from  the  rational  symp- 
toms. In  my  experience,  the  temperature-curve  is  a  very  useful 
guide  in  infants  who  give  no  evidence  of  pain.  Otoscopic  examina- 
tion is  the  only  positive  means  of  making  a  diagnosis.  There  is 
congestion  of  the  tympanum  above  Shrapnell's  membrane  and  the 
long  handle  of  the  malleus.  In  the  catarrhal  cases  the  tympanum 
is  red  and  angry  or  has  a  gTayish  lustre.  The  handle  appears  as 
a  red  or  yellowish-white  point.  In  some  cases  there  are  vesicles  and 
interlamellar  abscess.  The  exudate  may  cause  bulging  of  Shrap- 
nell's membrane  or  of  the  posterior-superior  quadrant.  Congestion 
remains  long  after  resolution.  In  the  suppurative  cases  the  epithe- 
lium of  the  tympanic  membrane  may  peel  off.  The  tympanum  is 
dull  and  lustreless.  The  auditory  canal  may  be  swollen.  Perfora- 
tion occurs,  chiefly  in  the  posterior-inferior  quadrant.  There  may 
be  pulsation  of  the  membrane  as  well  as  bulging.  The  lymph- 
nodes  beneath  the  ear  may  enlarge  and  that  region  may  be  very 
sensitive. 

Prognosis. — The  prognosis  in  ordinary  cases  is  good.  In  cases 
following  the  exanthemata  it  is  grave,  on  account  of  the  possibility 
of  complications  and  of  ultimate  loss  of  hearing. 


MASTOID  DISEASE. 


765 


Fig.  175. 


Mastoid  Disease. — General  Facts. — The  mastoid  region  is  impor- 
tant on  account  of  the  frequency  of  mastoid  disease  in  infancy  and 
childhood.  In  early  life  there  is  pneumatic  tissue,  but  no  mastoid  cells 
are  found.  The  mastoid  j)rocess  contains  one  large  cell  (Symington) 
(Fig.  175).  The  external  wall  is  less  thick  and  compact  than  in  the 
adult.  The  petrosquamous  suture  is  patent.  The  petrosquamous 
sinus  is  persistent  in  some  cases,  passes  through  a  foramen  on  the 
inside  of  the  skull,  and  appears  externally  behind  the  glenoid  fossa 
and  tympanic  ring.  Thus  infectious  material  may  easily  be  con- 
veyed internally.  In  infants  and  children  pus  finds  its  way  exter- 
nally more  readily  through  the  open  fissura  mastoideo-squamosa. 

Etiology. — Inflammation  of  the  mastoid 
is  rarely  primary.  The  mastoid  may  at 
the  outset  be  inflamed  when  there  has  been 
no  antecedent  otitis.  As  a  rule,  however, 
inflammation  of  the  mastoid  is  secondary 
to  acute  or  chronic  otitis.  The  causation 
is  identical  with  that  of  acute  or  chronic 
otitis. 

Of  39  cases  of  mastoid  disease  under 
eight  years  of  age,  collected  by  Knapp,  7 
occurred  in  the  first  year,  and  9  in  the 
second.  The  greatest  frequency  is  there- 
fore after  the  second  year.  It  may  occur 
as  early  as  the  second  month.  I  have  had 
a  case  in  an  infant  three  months  of  age. 
The  anatomical  conditions  favor  the  occur- 
rence of  mastoid  disease  in  infancy  and 
childhood.  The  Eustachian  tube  is  short  and  of  large  calibre ;  infec- 
tious material  from  the  nasopharynx  can  easily  gain  access  to  the  ear. 

Symptoms. — Clinically,  mastoid  disease  in  infancy  and  childhood 
manifests  itself  by  rational  symptoms  and  physical  signs.  There  may 
be  extensive  mastoid  disease  without  any  external  physical  signs.  In 
one  of  my  cases  of  otitis,  which  was  observed  by  an  expert  from  the 
outset,  extensive  mastoid  disease  in  a  child  of  three  years  of  age  did 
not  give  any  external  signs.  The  clinical  symptoms  are  character- 
istic. The  drum  may  have  been  perforated  after  otitis,  or  paracen- 
tesis may  have  been  performed.  After  perforation,  the  temperature 
present  during  the  preceding  otitis  drops  to  the  normal.  The  patient 
is  able  to  be  up  and  about.     The  ear  discharges  freely. 

After  two  or  three  weeks  there  is  a  sudden  or  gradual  rise  of 
temperature,  which  may  be  slight  or  may  reach  103°  or  105°  F. 
(39.4°  to  40.5°  C).  There  is  restlessness  at  night.  On  inspection, 
the  ear  may  not  show  anything  abnormal.     The  temperature,  how- 


-V. 


L'.S. 

Coronal  section  of  the 
mastoid  process  in  an  infant  3 
months  of  age.  This  is  the 
infantile  type  of  mastoid. 
(Symington.) 


766 


DISEASES  OF  THE  EAB. 


ever,  coiitiimes  to  be  remittent  for  several  clays.  On  otoscopic 
examination,  there  is  found  to  be  swelling  of  the  roof  of  the  auditory 
canal  or  of  the  floor  of  the  attic.  In  other  cases,  after  a  very  early 
and  timely  paracentesis  of  the  drum,  the  patient  does  not  do  well. 
The  child  is  restless  at  night,  at  intervals  irritable  and  then  playful, 
and  starts  from  sleep  (Fig.  176).  The  temperature  fluctuates  daily 
from  100.8°  to  102°  F.  (38.8°  C.) .  On  some  days  it  may  be  normal 
or  subnormal.  The  ear  discharges  for  days,  but  a  slight  temperature 
continues. 

If  the  patient  is  an  infant  or  a  young  child,  it  may  be  very  diffi- 
cult to  ascertain  whether  pain  is  present  on  pressure  backward  over 
the  region  of  the  antrum  behind  the  ear.  There  is  in  early  cases  no 
swelling  or  redness  behind  and  above  the  auricle.     As  was  stated 

Fig.  176. 


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otitis  media  in  a  female  child,  three  years  of  age.  Observed  from  the  onset.  Early 
paracentesis,  fall  of  temperature,  then  rise  again.  Subsequent  mastoid  involvement 
necessitating  operation. 


above,  there  may  be  extensive  and  advanced  mastoid  disease  without 
external  redness  or  swelling.  In  such  cases  the  lymph-nodes  behind 
the  ear  and  at  the  angle  of  the  jaw  may  be  swollen  and  painful. 
Young  children  and  infants  do  not  complain  of  pain.  It  is  only  in 
older  children  that  it  can  be  noted. 

Mastoid  disease  which  follows  the  exanthemata,  especially  scarlet 
fever  or  measles,  or  occurs  late  in  typhoid,  shows  certain  charac- 
teristic clinical  features.  During  the  fifth  or  sixth  week  of  scarlet 
fever  the  ears  may  discharge  profusely.  There  is  a  daily  rise  of 
temperature  in  the  afternoon,  which  is  slight  in  some  cases.  The 
patients  play  in  the  early  portion  of  the  day,  but  in  the  afternoon 
appear  listless,  and  have  a  slight  frontal  headache.  As  days  pass, 
the  children  become  stupid  during  the  afternoon  rise. 

In  many  cases  of  scarlet  fever  otitis  is  a  complication.  The  tem- 
perature does  not  fall  to  the  normal,  as  it  should,  after  the  fading  of 
the  eruption.  There  is  slight  aural  pain  at  night,  which  is  sometimes 
sufficiently  severe  to  deprive  the  patient  of  sleep.  In  other  cases  the 
temperature  drops  to  the  norma]  and  suddenly  rises  in  the  second 


MASTOID  DISEASE. 


767 


week.  In  both  these  sets  of  cases  there  is  an  otitis  which  may  develop 
into  mastoid  disease,  or  in  which  mastoid  disease  may  have  been 
present  from  the  outset. 

Korner  calls  attention  to  the  fact  that  in  late  typhoid  fever,  chills, 
with  rises  of  temperature,  may  be,  in  the  absence  of  other  signs, 
indicative  of  serious  mastoid  disease. 

Physical  Signs. — Pain. — Pain  is  a  physical  sign  of  mastoid  dis- 
ease in  children.  In  most  cases  it  cannot  be  elicited  by  the  most 
skillful  manipulation.  In  others,  on  account  of  the  fear  and  rest- 
lessness of  the  patient,  it  is  impossible  to  come  to  a  definite  conclu- 
sion. In  older  children  pain  may  be  elicited  by  pressing  the  mastoid 
bone  in  a  backward  direction,  care  being  taken  not  to  press  on  the 


Fig.  177. 


Mastoid  disease  in  a  child  eigliteen  months  of  age.      Swelling  behind  the  ear  over  the 
mastoid.     The  ear  is  displaced  away  from  the  scalp. 

auricle.  The  pressure  should  be  firm  and  continuous.  Pain  in  the 
tip  of  the  mastoid  is  not  of  value  unless  there  has  been  a  perforation 
and  phlegmon  at  that  point  (Dench). 

Otoscopic  Examination. — There  is  a  shortening  of  the  external 
canal  in  its  posterior  and  upper  aspect  (Dench).  The  upper  pos- 
terior wall  sinks.  There  is  bulging  of  the  upper  portion  of  the 
tympanum. 

Tumefaction. — Tumefaction  posteriorly  and  above  the  external 
structures  of  the  ear  occurs  in  infants  only  in  neglected  cases.  Ac- 
cording to  Dench,  in  these  cases  the  pus  escapes  from  the  antrum 
through  the  auditus  ad  antrum  into  the  tympanic  vault.  It  then 
finds  its  way  through  the  Eivinian  fissure  along  the  upper  wall  of 


768  DISEASES  OF  THE  EAR. 

the  canal  to  the  external  surface  of  the  mastoid.  In  children  cases 
in  which  this  swelling  appears  are  less  serions  than  adult  cases. 
The  swelling  also  appears  much  earlier  in  infants  and  children. 

Diagnosis. — The  life  of  the  patient  often  depends  upon  the  early 
recognition  of  mastoid  disease.  The  diagnosis  in  infancy  and  child- 
hood should  not  only  be  made  early,  but  should  be  made  chiefly  from 
the  clinical  symptoms  of  temperature,  which  will  in  its  fluctuations 
show  a  septic  curve,  and  from  the  physical  signs  and  otoscopic  exami- 
nation. The  history  of  the  case  is  of  service.  Presence  of  pain  is 
of  no  value  in  infants  and  young  children.  The  daily  otoscopic 
examination  of  the  discharging  ear  will  give  positive  evidence  of 
mastoid  disease.  The  signs  detailed  in  the  paragraph  on  symptoms 
are  of  great  importance.  A  profuse  discharge  does  not  preclude 
mastoid  disease.  Facial  paralysis  is  of  no  value.  I  have  seen  it  in 
cases  in  which  mastoid  disease  was  on  operation  found  to  be  absent. 
Tumefaction  is  seen  only  in  late  cases.  Redness  is  sometimes  ap- 
parent before  the  appearance  of  swelling  behind  the  ear. 

Course. — In  neglected  cases  pus  from  the  mastoid  may  force  its 
way  through  the  tympanic  roof  and  cause  cerebral  abscess  or  menin- 
gitis. It  may  destroy  the  plate  (lamina  vitrea)  of  the  sigmoid  sinus 
and  cause  thrombosis,  may  find  its  way  through  the  tip  of  the  mas- 
toid along  the  border  of  the  sternomastoid,  and  cause  phlegmon,  or 
may  force  itself  through  the  sutura  mastoideo-squamosa,  causing 
swelling  behind  the  auricle. 

Treatment. — Prophylaxis. — Children  can  be  taught  to  tolerate 
the  therapeutic  measures  which,  if  catarrhal  inflammation  of  the 
fauces  is  present,  as  in  the  exanthemata,  will  cleanse  the  parts.  Thus 
in  scarlet  fever,  an  intelligent  child  will  readily  allow  the  throat  to 
be  sprayed  with  normal  salt  solution.  Swabbing  the  throat  or  apply- 
ing any  drug  locally  is  impracticable  in  children. 

If  the  pain  is  excessive  a  mild  opiate,  such  as  paregoric,  is 
administered.  In  young  infants  the  severity  of  pain  cannot  be  esti- 
mated. In  older  children  dry  heat  applied  externally  to  the  ear  by 
means  of  a  water  cushion  relieves  the  pain.  Some  authors  advise 
the  application  of  leeches  behind  the  ear,  or  the  instillation  of  water 
at  110°  F.  (43.3°  C.)  into  the  canal  with  a  dropper.  Inflation  of 
the  ear  in  the  early  stages  of  otitis  media  has  been  advocated  and 
condemned. 

Suction  by  means  of  a  catheter  introduced  into  the  Eustachian 
tube  is  also  practised.  If  the  pain  and  fever  are  not  relieved  by 
these  measures,  incision  of  the  drum  is  resorted  to.  Whether  the 
otitis  is  catarrhal  or  purulent,  paracentesis  is  best  performed  early, 
since  damage  to  the  car  may  thus  be  avoided.  The  method  of  per- 
forming paracentesis  of  the  drum  is  best  learnt  from  special  text- 


MASTOID  DISEASE.  769 

books  on  the  subject.  Duel  advises  enlargement  of  the  opening  in 
cases  in  which  spontaneous  rupture  of  the  drum  has  taken  place. 
Drainage  bj  the  introduction  of  sterilized  absorbent  gauze  into  the 
canal  is  superior  to  syringing.  If  this  is  not  possible,  syringing 
with  1 :  5000  bichloride  is  useful. 

The  indications  for  the  performance  of  mastoid  operation  are 
protracted  otitis  with  profuse  otorrhcea,  there  being  no  tendency  to 
resolution,  acute  otitis  in  which  there  is  a  tendency  to  resorption 
and  in  which  paracentesis  has  not  established  drainage,  also  muco- 
purulent otitis  maintained  by  mastoid  involvement,  otitis  with  symp- 
toms pointing  to  meningeal  complications,  and  finally  otitis  with 
complicating  stenosis  of  the  external  canal,  preventing  drainage. 


49 


SE(  TION  XIY. 

DISEASES  OF  THE  KIDNEYS  AND  UROGENITAL 

TRACT. 

The  weight  of  the  kidneys  is  /ii;o  of  the  body  weight  in  the 
infant  and  /44o  in  the  adult. 

It  is  not,  as  a  rnle,  possible  to  palpate  the  normal  kidney  in  the 
infant  or  child.  I  have,  however,  seen  in  young  infants  exceptional 
cases  in  which  the  kidneys  Avere  situated  very  low  down  and  could 
be  easily  palpated  through  the  abdomen.  I  have  found  floating 
kidneys  in  infants  and  older  children,  but  not  so  frequently  as  other 
observers.  Comby  in  1898  reported  18  cases,  of  ages  ranging  from 
one  month  to  ten  years  of  age.  Steiuer.  Stewart,  and  Abt  have  also 
reported  a  number  of  cases.  I  believe  that  the  displaced  and  fixed 
kidney  is  congenital.  As  the  child  grows  and  the  parts  are  stretched, 
the  attachments  of  the  kidneys,  congenitally  low,  become  more  re- 
laxed. This  would  account  for  a  number  of  cases.  Jacobi  believes 
that  floating  kidney  in  children  is  a  congenital  anomaly. 

Sixteen  of  Comby's  cases  occurred  in  girls.  A  displaced,  fixed 
kidney  in  infants  canses  no  symptoms.  In  cases  of  movable  kidney 
or  floating  kidney  the  main  symptom  is  pain,  either  epigastric  or 
radiating  from  the  iliac  region.  In  a  girl  of  eight  years  with  float- 
ing kidney,  there  was  no  dilRculty  in  palpating  the  enlarged  movable 
kidney  below  the  liver.  There  were  attacks  of  acute  colicky  epigas- 
tric pain,  which  occurred  independently  of  the  ingestion  of  food. 
The  child  was  nervous  and  hysterical. 

DISEASES  OF  THE  KIDNEY. 

Cyclic  Albuminuria  (Fostural  Alhumimnia ;  Orthostatic  or  Lor- 
dotic Albuminuna). — Cases  of  this  form  of  albuminuria  were  first 
published  by  Vogel,  Ultzmann,  Gull,  and  Leube.  The  systematic 
description  was  first  given  by  Pavy.  by  whom  it  has  been  carefully 
studied. 

Cyclic  albuminuria  occurs  principally  in  children  and  adoles- 
cents; 40  per  cent,  of  the  cases  occur  in  children  from  the  first  to  the 
fifteenth  year,  and  80  per  cent,  of  the  cases  occur  before  the  twentieth 
year,  Jehle  places  the  greatest  frequency  from  the  sixth  to  the  four- 
teenth year.  It  is,  therefore,  distinctly  a  disease  or  condition  ob- 
served in  a  period  of  metabolic  activity  and  growth. 

770 


DISEASES  OF  THE  KIDNEY.  771 

Tlie  characteristic  symptom  is  the  appearance  of  albumin  in  the 
urine  in  the  forenoon  and  afternoon,  and  its  disappearance  after  a 
night's  rest  in  the  recumbent  position.  It  is  not  present  in  the  morn- 
ing directly  after  rising,  but  appears  soon  after  the  upright  position 
has  been  assumed. 

Mode  of  Occurrence. — Heubner  traces  a  connection  between  this 
form  of  albuminuria  and  the  position  of  the  body.  He  finds  that 
patients  excreted  albumin  when  their  position  was  changed  from 
recumbent  to  the  upright  posture ;  therefore,  during  rest  in  bed  there 
is,  in  such  individuals,  no  albuminuria.  But  it  regularly  appears 
when  they  get  out  of  bed  and  exert  themselves.  He  therefore  pro- 
posed the  term  orthostatic  albuminuria  for  these  cases. 

Etiology. — Jehle  points  out  the  relationship  of  this  form  of  albu- 
minuria to  lordosis  of  the  lumbar  vertebrae.  In  children  having  a 
marked  lordosis  in  the  upper  part  of  the  lumbar  spine  albuminuria 
occurred  in  the  upright  military  position  or  in  normal  children  in 
whom  an  over-accentuation  of  the  normal  lordosis  was  produced  arti- 
ficially or  by  some  form  of  exertion.  The  lordosis  causes  the  albu- 
minuria by  a  change  in  the  circulatory  conditions  of  the  kidnej^  The 
greatest  frequency  of  an  abnormal  lumbar  lordosis  and  therefore  of 
the  albuminuria  occurred  in  children  from  the  sixth  to  the  fourteenth 
year.     There  was  a  slight  preponderance  of  the  female  sex. 

There  is  no  doubt  as  to  the  existence  of  this  form  of  albuminuria 
in  children,  but  its  significance  is  a  matter  of  wide  diversity  of  opin- 
ion. Heubner  has  published  some  cases  and  collected  22  cases  in 
children  from  one  to  fifteen  years  of  age.  Some  authors,  among 
them  Heubner,  are  inclined  to  regard  them  as  physiological  forms  of 
albuminuria.  Others,  among  them  Henoch,  Leube,  and  Senator,  are 
inclined  to  regard  them  as  due  to  insidious  changes  in  the  kidney 
following  infectious  disease.  It  should  be  remembered  that  after 
influenza,  scarlet  fever,  or  diphtheria,  small  quantities  of  albumin 
are,  at  intervals,  present  in  the  urine  for  months  and  years.  There 
may  also  be  occasional  hyaline  or  epithelial  casts  and  a  few  blood- 
cells.  These  disappear  either  with  or  without  treatment  of  diet  and 
rest,  but  later  reappear.  I  have  seen  this  occur  in  children  in  good 
health. 

Symptoms. — The  Urine. — The  albuminuria  occurs  in  from  one  to 
three  or  five  minutes  after  the  erect  posture  is  assumed.  The  amount 
of  albumin  varies  from  a  trace  to  a  heavy  precipitate. 

The  presence  or  absence  of  form  elements  from  the  kidney  has 
been  a  matter  of  much  discussion  as  to  the  correct  interpretation  of 
their  presence.  Some  observers  (Heubner,  Langstein)  look  upon 
casts  and  blood  and  cylindroids  as  a  sign  of  disease  of  the  kidney, 
but  Jehle  goes  so  far  as  to  insist  that  at  the  moment  of  the  2;reatest 


772  DISEASES  OF  KIDNEYS  AND  UBOGENITAL  TRACT. 

albuminuria,  casts,  gi-auular,  hyaline  and  cylindroids,  and  even  blood, 
may  appear  to  disappear  when  the  so-called  insult  is  removed  from 
the  kidney  in  the  absence  of  any  nephritis.  Such  a  view  would 
appear  to  require  some  confirmative  observations.  It  should  be 
remembered  that,  in  nephritis,  the  albumin  in  the  urine  frequently 
takes  a  cyclic  course  (Senator). 

Prognosis  and  Course. — The  prognosis  must  remain  conditional 
on  the  prolonged  observation  of  the  patient  if  there  is  albumin 
in  the  urine,  for  a  few  of  the  published  cases  have  in  later  years 
developed  nephritis.  It  is  said,  also,  that  this  form  of  albuminuria 
has  been  met  in  several  members  of  the  same  family,  and  in  fami- 
lies in  which  albuminuria  and  nephritis  have  existed.  The  term 
cyclic  albuminuria  should,  it  seems  to  me,  for  the  present  be  lim- 
ited to  those  cases  in  which  there  has  never  at  any  time  previous 
to  or  during  observation  been  any  form-elements  of  the  kidney  in 
the  urine.  Many  of  the  cases  published,  and  those  which  I  have 
observed,  occurred  in  children  with  lymphatic  constitutions;  in 
others  there  was  scrofulosis  and  tuberculosis  (Pfaundler).  They 
showed  a  marked  ansemia  at  times.  There  was  an  oedema  of  the  face 
but  not  of  the  extremities.  The  children  complained  at  various 
times  of  headaches  or  a  heavy  feeling  in  the  occiput,  were  easily 
tired,  awoke  feeling  tired.  They  were  subject  to  dreams  and  were 
of  a  nervous  temperament.  In  one  of  my  cases  the  child  was  free 
from  the  above  symptoms,  and  was  the  picture  of  health.  In  this 
case  there  were  periods  early  in  the  disease  in  which  very  scanty 
form-elements  occurred  in  the  urine  with  the  albumin ;  at  others, 
none  could  be  found.  The  case  was  at  first  diagnosed  as  cyclic  albu- 
minuria; but  my  fears  have  been  justified,  inasmuch  as  lately  the 
form-elements,  such  as  casts  and  blood,  have  increased  in  the  urine 
and  have  become  permanent,  thus  showing  the  danger  of  diagnosing 
these  cases  on  short  periods  of  observation.  Two  cases  which  I  have 
seen,  after  many  repeated  examinations  (extending  over  a  year)  of 
the  urine,  failed  to  reveal  anything  ])ointing  toward  an  affection  of 
the  kidney.  The  albuminuria  is  present  some  time  after  rising  in 
tlio  morning,  and  after  exercise.     It  disappears  on  enforced  rest. 

Treatment, — It  has  been  proposed  in  cases  of  cyclic  albuminuria 
to  enforce  at  intervals  periods  of  rest  of  one  or  two  weeks  at  a  time, 
and  the  limitation  of  exercise  and  sports,  I  have  tried  this  method, 
at  the  same  time  dieting  -the  patient,  but  have  not  found  it  as  suc- 
cessful in  improving  the  general  condition  of  the  patient  as  moderate 
out-door  exercise  in  the  open  high  country — freedom  from  mental 
worry,  such  as  the  suspension  of  studies ;  good,  simple  food ;  perhaps 
a  tonic  of  the  iron  series.  City  and  school  life  are  not  conducive  to 
aiding  the  physician  in  treating  these  cases.      A  persistent  ana-mia 


DISEASES  OF  THE  KIDNEY.  773 

sets  in  under  these  conditions,  and  is  the  symptom  that  baffles  the 
physician  in  the  treatment.  ISTothing  will  improve  the  patient  so 
much  as  out-door  exposure  in  the  open  country. 

CEdema  or  Hydrsemia  without  Kidney  Lesion. — Weak  infants 
who  have  suffered  from  chronic  gastro-enteric  catarrh  have  swelling 
or  an  oedematous  condition  of  the  dorsum  of  the  feet  and  ankles. 
There  may  be  slight  anasarca  elsewhere.  There  is  no  real  kidney 
lesion;  the  condition  is  one  of  hydrsemia.  The  changed  state  of  the 
tissues,  including  the  vessels  and  blood,  allows  of  a  transudation  of 
serum  into  the  subcutaneous  structures.  On  examination,  the  urine 
is  found  to  be  abundant  and  of  low  specific  gravity,  but  without  evi- 
dences of  nephritic  degeneration.  In  children  of  two  years  of  age 
this  condition  of  slight  subcutaneous  oedema  occurs  in  simple  anaemia 
of  a  severe  type.  In  these  cases  the  skin  is  yellowish,  the  ears  have 
a  waxy  clearness,  the  eyes  have  an  oedematous  appearance,  and  the 
lips,  hands,  and  feet  are  puffy.  The  condition  is  known  as  hydrsemia 
or  hydrsemic  anaemia. 

Dysuria. — Dysuria,  or  difficult  and  painful  micturition,  is  a  con- 
dition in  which  there  is  partial  obstruction  to  the  free  flow  of  urine 
from  the  urethra.  It  is  not  uncommon  in  young  infants  and  chil- 
dren, and  may  be  due  to  a  variety  of  causes.  If  lithiasis  is  the  cause, 
there  is  not  only  pain  in  passing  the  urine,  but  there  may,  in  the 
intervals,  be  acute  attacks  of  pain,  due  to  the  passage  of  calculi  along 
the  ureter.  Examination  of  the  urethra  in  the  male  often  results  in 
finding  a  calculus  of  very  small  size  in  the  anterior  penile  urethra. 
In  lithiasis,  there  is  sometimes  very  painful  micturition  without  the 
formation  of  calculi  of  any  size.  The  minute  crystals  of  uric  acid 
cause  a  smarting  sensation  as  the  urine  passes  over  the  urethra.  In 
febrile  states  with  concentrated  urine,  the  acidity  of  the  urine,  and 
the  excess  of  uric  acid  with  free  crystals,  cause  painful  micturition. 

Simple  or  gonorrhoeal  inflammation  of  the  urethra  may  cause 
difficult  and  painful  micturition.  Dysuria  is  painful  at  the  onset  of 
vulvovaginitis. 

Cellular  Atresia  of  Labia. — Another  condition  of  congenital  origin, 
which  was  described  by  Bokai  as  cellular  atresia  of  the  labia,  is  a 
very  common  cause  of  dysuria.  It  is  seen  in  very  young  female 
infants.  From  birth,  the  urine  is  passed  in  drops  and  with  great 
straining  and  pain.  In  some  cases  it  is  passed  without  pain,  but  the 
condition  of  atresia  attracts  attention.  On  gently  separating  the 
labia  majora  a  thin  pinkish- white  membrane  is  seen  to  occlude  the 
introitus  vaginse  completely.  At  the  urethral  end  of  this  membrane 
a  very  minute  opening  is  seen,  through  which  the  urine  filters. 
These  membranes  can  be  divided  by  means  of  a  dull  director.  It  is 
then  seen  that  the  hymen  and  urethra  are  directly  behind  the  mem- 


774  DISEASES  OF  KIBNEYS  AXD  VEOGEXITAL  lEACT. 

brane.  The  operation  of  dividing  the  membrane  is  exceedingly 
simple  and  causes  little  or  no  bleeding. 

Bokai  has  described  a  similar  condition  in  boys,  which  is  some- 
what less  common.  It  is  a  cellular  adhesion  of  the  prepuce  and  glans 
penis  which  not  only  causes  false  phimosis,  but  also  difl&cult  and 
painful  urination.  He  found  that  in  the  newly  born  infant  the 
prepuce  was  sometimes  adherent  to  the  tip  of  the  glans  penis,  and 
that  across  the  opening  of  the  meatus  there  was  a  very  thin  mem- 
brane. In  other  cases,  this  membrane  was  ruj)tured,  but  the  prepuce 
still  remained  adherent  to  the  glans  in  front,  while  behind  at  the 
corona  glandis  there  was  retention  of  smegma  and  consequent  painful 
inflammation. 

The  treatment  is  division  and  separation  of  the  cellular  adhe- 
sions. Other  abnormalities  in  infant  boys,  among  them  diverticula 
of  the  urethra,  may  cause  dysuria. 

Hsematuria. — ^Hsematuria  is  the  passage  of  blood  and  its  elements 
into  the  urine,  in  which  blood-cells  and  coloring-matter  are  found. 
The  condition  may  occur  in  the  following  states : 

(a)  Acute  nephritis  of  all  forms,  especially  those  complicating 
the  infectious  diseases,  such  as  scarlet. fever,  measles,  typhoid  fever, 
and  malarial  fever. 

(h)   Calculi,  renal  or  vesical. 

(c)  Malignant  grovd;hs  of  the  kidney — sarcoma  and  carcinoma. 

(d)  Growths  of  the  bladder — polypus. 

(e)  Traumatism  in  the  region  of  the  kidney. 

(f)  The  ingestion  of  drugs.       ^ 

(g)  Scorbutus. 

The  color  of  the  urine  varies  from  a  slightly  smoky  amber  to  a 
deep  brovmish-red.  There  may  be  a  deposit  of  blood-cells  and  clots 
in  the  urine.  Pure  blood  with  clots  is  seen  in  cases  of  malignant 
tumor  of  the  kidney  and  calculi  of  the  kidney  or  bladder.  Smoky 
urine  is  seen  in  cases  of  nephritis  and  drug-poisoning. 

Hemoglobinuria. — Hsemoglobinuria  is  a  condition  in  which  the 
urine  contains  the  coloring-matter  of  the  blood,  but,  except  in  rare 
cases,  no  red  blood-cells.  The  urine  is  reddish  or  brownish,  and  has 
a  high  specific  gravity.  It  contains  albumin.  By  spectral  analysis 
the  spectrum  of  the  blood  coloring-matter  is  obtained.  According  to 
Hoppe-Seyler.  metha-moglobin  and  not  haemoglobin  is  often  the 
coloring-matter  present.     There  are  few  blood-cells  and  no  detritus. 

Etiology. — Several  theories  have  been  advanced  to  explain  the 
appearance  of  haemoglobin  in  the  urine,  that  of  Ponfick  being  gener- 
ally accepted.  According  to  that  author,  either  the  blood-cells  are 
destroyed  by  some  vicious  agent  or  ferment  (Ehrlich)  and  the 
haemoglobin  is  thus  let  loose  into  the  circulation,  or  the  haemoglobin 


DISEASES  OF  THE  KIDNEY.  775 

is  dissolved  out  of  the  blood-cells  and  passes  into  the  circulating 
plasma,  leaving  the  cells  behind  as  so-called  "  shadows."  Whatever 
the  real  cause,  the  exciting  influences  are : 

(a)  Cold  or  exposure  to  wet.  lloff  and  Demme  have  published 
cases  of  children  with  paroxysmal  hEemoglobinuria  following  such 
exposure. 

(&)   Drugs,  such  as  arsenic,  phosphorus,  potassium  chlorate. 

(c)  The  infectious  diseases,  such  as  malaria  and  scarlet  fever, 
erysipelas. 

(d)  Hsemoglobinuria  has  been  observed  in  cases  of  burns. 

(e)  Baginsky  has  observed  hsemogiobinuria  in  children  with 
nematodes. 

One-half  the  cases  published  have  a  history  of  syphilis.  Such  is 
the  case  published  by  Hermann,  occurring  in  a  boy  four  years  of 
age,  with  a  history  and  physical  marks  of  congenital  syphilis.  In 
this  case  the  boy  had  at  times  attacks  of  hsemoglobinuria. 

Symptoms. — In  the  paroxysmal  form,  each  attack  is  preceded  by 
a  chill  and  followed  by  dyspnoea,  palpitations,  cyanosis,  and  severe 
symptoms  of  collapse.  The  attack  may  last  a  few  hours  or  a  few 
days,  the  duration  depending  on  the  course  of  the  primary  affection. 
This  form  has  been  especially  observed  to  occur  in  pernicious  malar- 
ial fever. 

Prognosis. — The  prognosis  is  very  good.  Patients  quickly  recover 
from  the  attack  proper,  and  there  is  no  danger  to  life.  The  cases  of 
syphilitic  origin  are  not  controlled  by  antispecific  treatment,  though 
the  condition  of  the  blood  is  improved.  Chovostek  siucceeded  in 
abating  an  attack  by  the  administration  of  amyl  nitrite. 

Morbid  Anatomy. — Dieulafoy  and  Widal  found  in  a  fatal  case  the 
cortex  of  the  kidney  dark  brown  in  color ;  the  cells  of  the  glomeruli 
were  n.ormal.  The  cells  of  the  convoluted  tubes  and  the  tubes  of 
Henley  were  infiltrated  with  pigment-granules,  which  were  also  pres- 
ent in  the  lumen  of  the  tubes. 

Treatment. — The  treatment  consists  not  only  in  the  management 
of  the  primary  exciting  conditions,  but,  if  there  is  a  history  of  syph- 
ilis, an  antispecific  course  of  treatment  is  indicated.  With  this  we 
may  give  tonics,  such  as  iron,  and  exert  a  certain  amount  of  pro- 
phylaxis by  protecting  the  patient  from  cold,  and  also,  if  possible, 
securing  to  the  patient  wholesome  food. 

Renal  Calculi  (Uric  Acid  Infarction;  Lithcemia). — So-called  uric 
acid  infarction  is  found  in  the  kidneys  of  over  one-half  the  infants 
who  die  in  the  first  weeks  of  life.  These  infarctions  are  seen  in  the 
medullary  portion  of  the  kidney  as  golden-yellow  or  brownish  rays 
which  are  broader  toward  the  papilla.  Epstein  found  isolated 
deposits  in  the  cortex.     The  infarctions  consist  of  uric  acid  (Schloss- 


776  DISEASES  OF  KIDNEYS  AND  UROGENITAL  TRACT. 

berger).  They  are  supposed  to  be  due  to  the  destruction  of  tissue 
rich  in  nuclein  (cells)  (Kossel  and  Horbaczewski).  They  are 
found  in  weaklings,  and  more  often  in  infants  who  have  been  born 
living  than  in  stillborn  infants.  During  the  first  weeks  of  life  they 
are  washed  out  by  the  urinary  secretion.  Hence  the  increased 
uric  acid  excretion  at  that  time.  As  a  rule  the  condition  gives  no 
symptoms. 

It  is  not  uncommon  for  the  diapers  of  the  infants  to  be  stained 
red,  and  in  older  children  there  may  be  the  so-called  brick-dust 
deposit  in  the  urine.  In  these  cases  there  may  be  a  history  of  severe 
colicky  attacks.  In  other  cases  the  infant  or  child  experiences  pain 
on  urination  and  cries  piteously.  Some  older  children  will  run  about 
in  pain  and  grasp  the  penis.  In  all  such  cases  the  diapers  should  be 
examined  for  concretions.  Failing  to  find  these,  the  urethra  is  care- 
fully explored. 

In  several  cases  I  have  found  an  oval  calculus  of  the  size  of  a 
rice-seed,  imbedded  in  the  canal  of  the  penile  portion  of  the  urethra. 
These  cases  have  attacks  of  pain  extending  over  months,  probably 
caused  by  the  passage  of  the  calculi  from  the  kidney  through  the 
ureter,  the  bladder,  and  urethra.  The  calculi  are  easily  extracted 
with  long-bladed  forceps.  In  one  of  my  cases  of  hematuria,  in  a 
boy  three  years  of  age,  there  were  several  attacks  lasting  for  days, 
but  no  distinct  history  of  pain.  The  urine  contained  blood  coloring- 
matter,  some  blood-cells,  and  a  few  hyaline  casts.  The  diagnosis 
was  obscure  until  a  few  small  calculi  were  found  in  the  urine.  Uro- 
tropin  given  in  small  doses  caused  a  cessation  of  symptoms. 

Acute  Nephritis. — A.  Acute  Parenchymatous  Nephritis  or  Acute 
Exudative  Nephritis  (Delafield)  ;  Tubular  or  Glomerular  Ne- 
phritis. B.  Acute  Diffuse  Nephritis  or  the  Acute  Productive  Ne- 
phritis (Delafield). — Etiology. — The  etiology  of  both  forms  of 
acute  nephritis  is  the  same. 

There  is  scarcely  an  acute  infectious  febrile  disease  which  may 
not  give  rise  to  acute  nephritis.  It  complicates  or  follows  scarlet 
fever,  measles,  influenza,  diphtheria,  infectious  angina,  pneumonia, 
rheumatism,  typhoid  fever,  sepsis  of  all  kinds,  variola,  parotitis, 
malaria,  and  congenital  syphilis.  The  frequency  in  scarlet  fever  of 
the  (Edematous  forms  with  anasarca  has  led  to  the  belief  that  this 
disease  was  most  often  complicated  by  nephritis.  If  the  parenchy- 
matous form  is  included,  the  condition  will  be  found  to  be  very  fre- 
quent in  other  infedious  diseases,  but  it  is  often  unrecognized. 

The  essential  causes  of  acute  nephritis  are  micro-organisms  or 
their  toxins.  Thus  in  the  various  diseases,  the  Diplococcus  pneu- 
moniae, the  typhoid  bacillus,  streptococci  of  various  kinds,  staphylo- 
cocci, and  the  Bacillus  pyooyancus,  have  among  other  bacteria  been 


DISEASES  OF  THE  KIDNEY.  Ill 

found  in  the  kidney.  On  the  other  hand,  in  diseases  such  as  diph- 
theria, the  toxins  of  the  bacteria  are  the  cause  of  the  parenchymatous 
or  diffuse  nephritis  (Flirbringer,  Roux,  Councilman).  If  the  toxins 
are  formed  in  the  body,  the  infections  are  said  to  be  autochthon  or 
endogenous.  The  irritating  toxin  may  be  introduced  from  without, 
as  in  chloroform  or  ether  narcosis,  and  the  ingestion  of  drugs  (ectoge- 
nous).  The  role  played  by  cold  as  a  causative  factor  is  still  a  matter 
of  speculation.  Its  mode  of  action,  whether  reflex,  through  the 
circulation,  or  by  causing  changes  in  the  blood,  is  still  obscure. 

Morbid  Anatomy. — Acute  Parenchymatous  or  Exudative  Nephri- 
tis (Delafield). — This  is  an  acute  inflammation  of  the  kidney,  in 
which  the  principal  changes  occur  in  the  epithelium  of  the  tubules 
and  Malpighian  tufts.  The  kidneys  are  larger  than  normal,  and 
succulent.  The  capsule  can  be  stripped  from  the  surface,  which  is 
red,  grayish,  and  punctate  in  spots.  All  the  changes  are  most 
marked  in  the  cortex  of  the  kidney.  Evidences  of  inflammation  are 
found  in  the  tubes,  stroma,  and  glomeruli.  The  epithelium  of  the 
tubes  is  flattened,  granular,  and  fatty,  or  in  a  condition  of  coagulation- 
necrosis.  The  lumen  of  the  tubules  may  be  empty  or  may  be  filled 
with  desquamated  epithelium  or  with  coagulated  masses  (casts)  of  a 
hyaline  character.  Delafield  describes  the  tubes,  in  severe  cases,  as 
flUed  with  leucocytes  and  blood-cells.  The  tubes  may  be  uniformly 
dilated. 

The  changes  in  the  glomeruli  may  be  so  slight  as  to  be  scarcely 
noticeable.  The  cavities  of  the  capsules  sometimes  contain  coagu- 
lated matter  and  red  and  white  blood-cells  (Delafield).  In  marked 
cases  there  are  desquamation  of  capsular  epithelium  and  increase  of 
nuclei.  The  swelling  and  proliferation  of  cells  sometimes  change  the 
appearance  of  the  tuft  so  that  the  outlines  of  the  individual  capillaries 
are  lost.  The  stroma  is  infiltrated  with  serum,  and  in  severe  cases 
there  are  in  the  cortex  small  collections  of  white  blood-cells  (pus). 

Acute  Diffuse  N ephritis. — The  changes  in  acute  diffuse  nephritis, 
or  the  acute  productive  nephritis  of  Delafield,  are  more  serious  and 
permanent.  According  to  Delafield,  the.  kidneys  are  large,  and  at 
first  smooth  and  later  rough.  The  cortex  may  be  mottled  yellow 
and  red ;  the  pyramids  are  red. 

In  this  form  of  nephritis  there  are  the  changes  found  in  exudative 
nephritis,  and  also  a  growth  of  connective  tissue  in  the  stroma  and 
an  increase  of  the  capsule  cells  of  the  Malpighian  bodies.  These 
changes  involve  symmetrical  strips  of  the  cortex,  which  follow  the 
lines  of  the  arteries  (Delafield).  The  Malpighian  bodies  show  an 
enormous  growth  of  capsule  cells  with  compression  of  the  tufts.  If 
the  nephritis  is  acute,  the  interstitial  tissue  is  augmented  with  newly 
formed  cells  and  basement  substance.     There  is  a  new  growth  of 


778  DISEASES  OF  KIDNEYS  AND  UEOGENITAL  TEACT. 

connective  tissue  between  the  tubules ;  the  walls  of  the  arteries  are 
thickened.  In  the  capsule  of  the  Malpighian  tuft  there  is  a  growth 
of  cells  which  compress  the  tuft  of  vessels.  These  and  the  vessels 
are  in  turn  converted  into  small  balls  of  fibrous  tissue  (Delafield). 
In  addition  there  may.  in  the  acute  forms  of  nephritis,  be  hemor- 
rhages throughout  the  kidney  substance. 

Ssanptoms. — In  the  forms  of  parenchymatous  nephritis  which 
complicate  the  febrile  infectious  diseases,  influenza,  pertussis,  angina, 
and  gastro-enteritis,  either  the  symptoms  of  the  primary  disease 
mask  those  due  to  the  kidney  lesion  or  the  nephritis  may  be  so  mild 
as  to  give  no  symptoms.  Thus  in  the  parenchymatous  nephritis 
which  complicates  or  follows  influenza,  there  are  after  the  attack  has 
passed  no  symptoms  referable  to  the  kidneys,  yet  on  examination  the 
urine  shows  a  trace  of  albumin,  hyaline  and  a  few  epithelial  casts, 
and  an  occasional  red  blood-cell.  In  these  cases  there  is  no  oedema 
of  the  tissues,  no  headache,  and  the  children  are  apparently  well 
except  for  the  changes  in  the  urine.  These  may  at  first  be  quite 
marked.  After  a  few  months  the  albumin  may  only  appear  occa- 
sionally; the  casts  and  blood  disappear  for  weeks  and  then  reappear. 
For  weeks  or  months  the  children  may  have  no  constitutional 
symptoms. 

In  the  parenchymatous  nephritis,  which  is  seen  in  severe  forms 
of  gastro-enteritis  and  dysentery,  the  signs  in  the  urine  of  marked 
nephritis  are  albumin,  casts  of  all  kinds,  and  blood-cells  (Parrot, 
Fischl,  Czerny,  Koplik,  and  Morse).  Although  Czerny  traces  a  cer- 
tain form  of  dyspnoea  to  the  infiuence  of  uraemia  in  these  cases,  no 
distinct  set  of  symptoms  due  to  the  kidney  can  yet  be  formulated. 
It  is  true  that  there  are  terminal  anasarca,  suppression  of  urine,  and 
vomiting,  but  the  presence  of  all  these  may  be  ex|flained  by  the 
severity  of  the  intestinal  lesions  and  toxemia. 

CiiAXGES  I^'  THE  Ueizst.. — In  all  the  diseases  above  mentioned, 
the  parenchymatous  nephritis  may  in  infants  and  children  be  evinced 
by  diminution  of  the  quantity  of  urine,  or  the  presence  of  a  trace  of 
albumin,  or  a  few  hyaline  or  epithelial  casts  and  blood-cells.  The 
quantity  of  urine  may.  however,  be  normal.  In  other  cases,  the 
albumin  is  more  marked  and  the  casts  much  more  numerous.  Renal 
epithelium  is  also  present.     Leucocytes  are  rare. 

In  the  diffuse  or  productive  form  of  nephritis  in  infants  and 
children,  the  symptoms  are  marked.  In  some  forms  of  nephritis 
complicating  scarlet  fever  the  lesion  never  advances  beyond  the 
parenchymatous  stage,  and  at  that  period  the  symptoms  are  either 
not  present  or  not  noticeable.  If  the  nephritis  is  more  marked,  how- 
ever, it  is  noticed  at  the  end  of  the  third  week  that  the  patient  is 
somewhat  pale,  that  the  face  is  a  little  swollen,  especially  aboi/t  the 
eyes,  and  that  there  is  very  slight  oedema  of  the  general  surface. 


DISEASES  OF  THE  KIDNEY.  779 

In  these  cases  it  is  possible  at  the  end  of  the  period  of  ernption 
to  find  a  slight  trace  of  albumin  in  the  urine  and  a  few  hyaline  and 
epithelial  casts.  With  the  onset  of  the  anasarca  the  albumin  in- 
creases in  quantity,  the  casts  in  number,  and  a  few  blood-cells  are 
found.  The  quantity  of  urine  is  diminished,  but  in  the  mild  forms 
not  markedly  so.  A  boy  of  six  years  may  pass  half  the  normal  quan- 
tity. There  is  no  headache,  and  only  a  few  obscure  pains  in  the 
joints.  There  is  occasionally  slight  pain  in  the  region  of  the  kidney. 
The  temperature  is  normal  or  may  at  intervals  of  several  days  rise 
a  degree  or  a  degTee  and  half  above  the  normal.  The  nephritis  is 
probably  of  the  mild  diffuse  type.  In  three  weeks  the  moderate 
anasarca  disappears,  the  ansemia  improves,  and  the  urine  becomes 
normal. 

In  the  more  severe  cases  there  is  a  rise  of  one  or  two  degrees 
in  temperature,  and  the  patients  have  marked  general  anasarca.  If 
old  enough,  they  complain  of  headache,  they  vomit,  and  show  marked 
decrease  in  the  number  of  respirations  and  pulse,  the  irregularity 
of  pulse  being  of  a  purely  ursemic  character.  In  some  cases  there 
are  effusion  into  the  chest  (hydrothorax)  and  abdominal  ascites. 

The  quantity  of  urine  is  much  diminished,  there  being  only  one 
or  two  ounces  in  twenty-four  hours.  The  specific  gravity  is  high; 
the  urine  contains  blood,  leucocytes,  and  casts  (hyaline,  granular, 
and  epithelial),  with  blood  cells.  Under  treatment,  the  vomiting, 
headache,  and  anasarca  subside,  the  quantity  of  urine  increases,  the 
number  of  casts  and  blood-cells  diminishes,  and  the  patient  makes 
a  good  recovery.  In  other  cases  the  initial  anasarca  becomes  more 
marked,  there  being  considerable  oedema  of  the  whole  surface ;  the 
urine  is  entirely  suppressed;  the  vomiting  and  headache  increase; 
convulsions  set  in ;  there  are  several  attacks  of  eclampsia ;  the  patient 
becomes  comatose,  and  may  die  of  uraemia,  or  after  one  or  two  attacks 
of  eclampsia,  the  symptoms  may  abate  and  recovery  take  place. 

There  is  a  very  fatal  form  of  diffuse  nephritis  which  occurs  on 
the  fourth  or  fifth  day  of  malignant  scarlet  fever.  On  the  third  day, ' 
at  the  height  of  the  eruption,  the  patient  passes  into  a  delirious,  semi- 
conscious state.  The  quantity  of  urine  is  much  diminished;  its 
specific  gravity  is  high ;  casts  of  all  kinds  and  blood  are  present.  The 
urine  may  finally  be  totally  suppressed.  There  is  no  oedema  of  the 
surface.  Coma  and  convulsions  set  in.  The  patient  succumbs  to 
the  intense  general  toxsemia  and  to  its  effect  on  the  kidneys.  In 
these  cases  the  kidney  symptoms  cannot  be  separated  from  those 
caused  by  the  general  intoxication. 

Individual  Symptoms. — Vomiting. — The  vomiting  in  scarla- 
tinal nephritis  is  rarely  distressing,  and  subsides  in  a  short  time.  It 
is  not  a  constant  symptom,  nor  is  it  of  serious  import. 


780  DISEASES  OF  EIDXETS  AND  UEOGENITAL  TSACT. 

Headache. — The  headache  is  not  a  very  marked  symptom  in 
children. 

Oedema. — (Edema  is  present  in  a  large  jDroportion  of  cases,  and 
is  marked  in  the  severe  ones.  It  may  occur  with  hydrothorax, 
ascites,  and  hydropericardium.  It  maj  affect  only  the  face,  or  the 
lower  extremities  alone.  It  may  be  so  intense  as  to  cause  bursting 
of  the  skin  and  the  escape  of  serum  through  the  fissures.  It  may 
affect  one  half  the  body  more  than  the  other  (Henoch).  Under  all 
these  conditions,  the  outlook  is  serious. 

Pulse. — The  pulse  is  sometimes  inordinately  slow.  It  may  be 
m.ore  rapid  than  normal,  and  may  show  marked  irregularity. 

Heart. — The  heart  may,  as  was  pointed  out  by  Henoch  and 
Friedlander,  be  the  seat  of  hypertrophy  and  dilatation.  There  may 
be  complicating  endopericarditis. 

Lungs. — The  lungs  may  be  the  seat  of  pneumonia,  or  cedema  of 
the  lungs  may  suddenly  develop.  There  may  be  complicating 
pleuritis. 

Constipation.  —  There  may  be  constipation  or  more  or  less 
diarrhoea. 

Temperature. — There  are  cases  in  which  the  temperature  is 
normal  or  subnormal  during  the  whole  course  of  the  disease.  In  the 
cases  in  which  there  are  sudden  eclamptic  seizures,  the  temperature 
may  mount  to  104^  F.  (40^  C.)  during  the  attacks.  On  account 
of  the  rupture  of  a  bloodvessel  in  the  brain  during  the  eclamptic 
seizures  there  is  in  many  cases,  after  the  subsidence  of  the  ursemic 
symptoms,  aphasia,  or  hemiplegia  o5  a  more  or  less  permanent  nature. 

Fainting  Spells. — Patients  with .  nephritis  succeeding  scarlet  fever 
develop  fainting  spells  with  cyanosis,  gallop-rhythm,  and  all  degrees 
of  cardiac  weakness.  It  is  difficult  in  such  cases  to  know  whether 
to  attribute  these  symptoms  to  the  nephritis  or  to  myocarditis  which 
is  the  result  of  the  scarlet  fever. 

Urine. — The  general  characteristic  features  of  the  urine  in  acute 
diffuse  nephritis  of  scarlet  fever  have  been  given.  Suppression  may 
take  place  suddenly.  The  urine  may  not  have  contained  coagulable 
albumin  or  easts,  and  the  quantity  may  have  been  normal.  The 
common  notion  that  uraemia  or  eclampsia  can  supervene  only  if  the 
quantity  of  urine  is  diminished,  is  erroneous.  Even  if  the  quantity 
is  above  the  normal  and  the  urine  contains  little  albumin  and  few 
casts,  eclampsia  may  supervene  with  fatal  results.  An  increase  in 
the  quantity  of  urine  above  that  of  the  normal  is  an  unfavorable 
symptom  unless  temporary  and  accounted  for  by  the  treatment. 
The  quantity  of  urea  passed  is  always  the  crucial  test.  There  are 
eases  in  which  blood  appears  in  the  urine  and  in  which  there  is  true 
haemoglobinuria,  which  may  give  rise  to  irritation  of  the  kidney.     In 


DISEASES  OF  THE  KIDNEY.  781 

Other  words,  the  hsemoglobinuria  is  primary,  the  nephritis  secon- 
dary. The  quantity  of  albumin  in  the  urine  varies  greatly;  it  may 
only  amount  to  a  trace  or  be  sufficient  to  cause  the  urine  to  become 
solid  when  boiled. 

Primary  Forms  of  Acute  Nephritis. — The  question  has  arisen:  Can 
nephritis  be  primary?  If  nephritis  is  the  result  of  some  form  of 
infection,  it  cannot  be  primary.  Henoch,  Heubner,  Bouchut,  Bartels, 
Loos,  and  Holt  have  published  cases  in  nurslings,  the  origin  of  which 
could  not  be  traced.  These  occurred  in  infants  from  five  weeks  to 
one  and  a  half  years  of  age,  who  suddenly  developed  marked  anasarca 
and  vomiting,  with  suppression  of  urine.  Some  of  the  cases  had  a 
febrile  movement  of  a  remittent  type.  The  majority  of  them  were 
fatal.  Their  exact  nature  is  still  unknown.  Uhlenbrock  has  re- 
cently collated  all  the  cases  in  the  literature,  but  has  thrown  no  light 
on  the  subject.  On  autopsy,  a  few  cases  have  shown  a  parenchy- 
matous nephritis. 

Course. — The  majority  of  cases  of  parenchymatdus  or  exudative 
nephritis  recover.  The  prognosis  of  the  diffuse  or  productive  form 
is  more  serious,  but  in  exceptionally  mild  cases  recovery  may  take 
place.  Others  cases  make  an  apparent  recovery.  After  the  symp- 
toms of  oedema  and  anasarca  have  disappeared,  ansemia  remains. 
The  albumin  in  the  urine  may  disappear  and  reappear.  In  six 
months  or  a  year,  general  anasarca  may  set  in  with  all  the  symptoms 
of  an  acute  exacerbation  of  the  disease.  The  patient  may  eventually 
recover  from  the  attack,  but  as  a  rule  others  of  the  same  kind  follow, 
and  the  condition  of  chronic  nephritis  results. 

Duration, — The  acute  forms  of  parenchymatous  or  diffuse  neph- 
ritis last  from  two  to  six  weeks.  The  parenchymatous  forms  are 
sometimes  evanescent,  the  marked  symptoms  lasting  only  a  week. 

Chronic  Diffuse  Nephritis.. —  (a)  Chronic  Productive  Nephritis,  (h) 
Chronic  Nephritis  ivithout  Exudation  (Delafield). — The  forms  of 
chronic  diffuse  nephritis  are  the  same  in  childhood  as  in  adult  life. 
They  usually  occur  late  in  childhood.  Thus  one  case  of  chronic 
diffuse  nephritis  in  a  girl  of  fourteen  years  of  age  dated  from  an 
attack  of  scarlet  fever  at  the  age  of  eight  years.  At  autopsy  there 
was  found  a  diffuse  nephritis  of  the  productive  variety  (large  white 
kidney).  In  another  case,  a  boy  of  t^yelve  years,  with  diffuse  neph- 
ritis of  the  non-productive  variety  (small  cirrhotic  kidney),  had  had 
an  attack  of  scarlet  fever  at  the  age  of  five  years.  He  had  no 
anasarca  in  the  course  of  the  nephritis.  Active  symptoms  of  head- 
ache and  vomiting  appeared  a  year  and  a  half  before  his  death.  The 
quantity  of  urine  was  above  the  normal  and  there  were  a  few  hyaline 
casts.  At  autopsy  a  small  kidney  was  found.  Thus  there  may  in 
children  be  two  forms  of  chronic  nephritis  following  scarlet  fever 


782  DISEASES  OF  KIDNEYS  AND  UROGENITAL  TBACT. 

or  any  other  infectious  disease.  Adults  present  symptoms  referable 
to  the  eye,  such  as  neuroretinitis,  which  I  have  not  met  with  in  chil- 
dren, and  which  must  be  exceedingly  rare  in  them.  ISTeither  have  I  seen 
in  children  the  emphysema  met  in  adults.  The  heart  may  be  hyper- 
trophied  and  dilated  in  children  as  in  the  adult.  They  may  have 
endocarditis  and  pericarditis  with  pleurisy. 

Treatment. — The  forms  of  parenchymatous  or  exudative  nephritis 
which  so  frequently  occur  as  accompaniments  of  the  acute  febrile  dis- 
orders, pneumonia,  typhoid  fever,  influenza,  etc.,  need  little  or  no 
treatment.  There  are  no  symptoms  referable  to  the  kidney,  l^eph- 
ritis  accompanying  acute  gastro-enteritis  is  best  treated  by  remedies 
directed  toward  the  primary  affection.  The  quantity  of.  urine  is 
sometimes  diminished.  It  contains  casts  of  all  kinds.  Rectal  ene- 
mata  of  saline  solution  at  a  temperature  of  108°  F.  (42.2°  C.)  are 
then  of  great  utility,  not  only  in  supplying  fluid  to  a  depleted  circu- 
lation, but  also  in  stimulating  the  circulation  and  therefore  the  kidney 
secretion.  Drugs  which  might  still  further  compromise  the  condi- 
tion of  the  kidney  should  not  be  given  for  the  intestinal  affection. 
Hot  baths  are  of  great  utility,  105°  F.  (40.5°  C). 

In  the  partial  or  complete  suppression  of  urine  seen  in  the  first 
few  days  of  the  malignant  forms  of  scarlet  fever,  more  active  treat- 
ment is  required.  When  the  temperature  is  high,  the  pulse  rapid 
and  weak,  the  patient  unconscious  or  delirious,  and  the  urine  dimin- 
ished or  suppressed,  I  administer  high  and  large  rectal  enemata  of 
water  at  a  temperature  of  108°  to  110°  F.  (42.2°  to  43.3°  C),  as 
recommended  by  Kemp.  These  should  not  be  given  to  children  with 
a  double-current  tube,  but  simply  as  enemata.  About  a  quart  of 
saline  solution  is  thrown  into  the  rectum  at  very  low  pressure.  A 
fountain  bag  syringe  is  utilized  for  this  purpose.  These  enemata 
stimulate  the  heart  and  circulation  and  supply  the  system  with 
normal  fluid.  To  stimulate  the  skin,  the  warm  baths  are  preferable 
to  cold  ones.  Patients  are  frequently  much  depressed  by  cold  packs 
or  baths  given  to  reduce  the  temperature.  The  temperature  of  the 
bath  should  be  at  least  105°  F.  (40.5°  C),  and  the  patient  allowed  to 
remain  in  it  five  or  ten  minutes,  according  to  the  state  of  the  pulse. 

In  acute  cases  the  anasarca  will,  as  a  rule,  take  care  of  itself.  If 
it  is  extreme.  Senator  advises  the  administration  of  diuretics  in  acute 
as  well  as  chronic  nephritis.  Some  authors  recommend  diuretin  and 
digitalis  in  form  of  infusion,  a  drachm  being  combined  with  an 
agreeable  alkali,  such  as  citrate  of  potassium.  The  pulse  should  be 
watched.  If  it  is  low,  the  digitalis  is  suspended.  I  do  not  utilize 
whiskey  or  alcohol  in  these  cases.  In  acute  diffuse  nephritis  and 
in  productive  nephritis  similar  to  that  of  scarlet  fever,  the  ursemic 
symptoms,  the  oedema,  and  the  kidneys  are  treated.     Vomiting  is  a 


DISEASES  OF  THE  KIDNEY.  783 

m-gemic  symptom  whicli  is  prominent  at  first.  If  tlie  patient  vomits 
everything  ingested,  no  food  should  be  given  by  month.  The  patient 
is  nourished  by  rectum  by  means  of  somatose  or  nutritive  enemata. 

The  headache  needs  little  treatment.  Bromide  and  a  small  dose 
of  chloral  or  trional  are  given  for  restlessness  at  night.  In  the  forms 
of  nephritis,  generally  subacute,  in  which  there  are  oedema  amount- 
ing to  anasarca,  and  diminution  of  urine,  baths  and  diuretics  are 
beneficial.  The  anasarca  is  sometimes  scarcely  noticeable,  and  the 
quantity  of  urine  little  diminished.  There  are  usually  a  few  hya- 
line and  epithelial  easts,  and  also  blood-casts.  The  patient  is  kept 
in  bed  and  put  on  a  milk  diet.  The  bowels  are  kept  open  by  means 
of  Vichy  water  given  in  liberal  quantities,  or  by  Carlsbad  salts.  A 
child  between  four  and  six  years  of  age  should  take  half  a  drachm 
of  the  salts  once  a  day.  Some  mild  diuretic,  such  as  citrate  or  ace- 
tate of  potassium,  is  given.  The  pulse  may  be  80  or  90,  and  digi- 
talis is  therefore  not  given.  Under  this  mild  therapy  the  anasarca 
subsides,  the  albumin  diminishes,  and  the  urea  and  quantity  of  urine 
increase.  Milk  also  tends  to  increase  the  quantity  of  urine.  A 
bath  at  104°-105°  F.  (40°  C.)  is  given  every  day  or  every  second 
day  according  to  the  indications.  The  diaphoretic  efi^ects  of  vapor 
baths  are  less  marked. 

In  some  of  the  severer  cases  the  urine  is  greatly  diminished,  the 
anasarca  extreme,  the  pulse  and  respirations  are  increased,  and  the 
temperature  may  be  elevated.  The  anasarca  is  then  treated  by  a 
daily  warm  bath,  in  which  the  patient  remains  for  five  minutes,  and 
is  then  wrapped  in  a  warm  dry  blanket  to  promote  diaphoresis.  A 
warm  rectal  enema  at  the  temperature  above  mentioned  is  given  twice 
daily.  The  kidneys  are  stimulated  by  means  of  digitalis  and  ace- 
tate, citrate,  or  tartrate  of  potassium. 

The  digitalis  is  given  in  form  of  the  infusion,  5ss-3j  with  3  to  8 
grains  of  the  potassium  salt,  three  or  four  times  daily.  The  pulse 
is  closely  watched  and  not  allowed  to  fall  too  low.  The  bowels  are 
kept  open  by  the  daily  administration  of  cathartics.  If,  as  fre- 
quently happens,  the  heart  becomes  weak,  sparteine  or  liq.  ammonite 
acetatis  and  nitroglycerin  may  also  be  given.  I  do  not  administer 
preparations  of  musk  or  camphor  in  nephritis.  Convulsions  are 
best  controlled  by  means  of  chloroform.  Warm  baths  and  high  warm 
enemata  are  also  useful.  Bromide  and  chloral  are  also  given  by" 
rectum,  as  in  ordinary  eclampsia. 

In  convalescence  the  question  arises.  When  shall  diuretics  be 
discontinued?  As  soon  as  the  quantity  of  urine  is  above  the  normal, 
they  are  of  no  further  value.  The  baths  and  enemata  are  continued 
as  long  as  there  is  the  least  oedema  of  the  surface.  Warm  enemata 
should  not  be  continued  after  the  urine  has  increased  to  the  normal 


784  DISEASES  OF  KIDNEYS  AND  UBOGENITAL  TRACT. 

amoimt.  Ordinary  enemata  are  then  given  for  the  purpose  of  aid- 
ing the  cathartics  in  keeping  the  bowels  open  and  clear  of  fsecal 
accumulations. 

Rest  in  bed  should  be  continued  until  there  is  no  palpable  albu- 
min reaction.  Meat  and  vegetables  are  then  added  to  the  diet  list. 
If  ansemia  is  present,  a  readily  assimilable  form  of  iron,  such  as  the 
peptonate,  is  given.  Casts  will  appear  in  the  urine  far  into  conva- 
lescence. The  patients  may,  however,  be  allowed  to  be  up  if  they 
bear  the  change  well.  A  too  protracted  stay  in  bed  is  sometimes 
exhausting  in  summer.  If  symptoms  of  anasarca  and  other  signs 
of  nephritis  recur,  the  treatment  is  the  same  as  in  primary  acute 
attacks.  The  treatment  of  chronic  nephritis  in  children  does  not 
differ  from  that  followed  in  the  adult.  I  have  recently  subjected 
two  children  who  suffered  from  the  chronic  diffuse  form  of  nephritis 
following  scarlet  fever,  accompanied  by  recurrent  attacks  of  anasarca 
extending  over  years,  to  Edebohl's  operation  of  splitting  or  extirpa- 
tion of  the  kidney  capsule.  Both  cases  were  much  benefited  by  the 
operation.  One  case  was  free  from  symptoms  for  fully  a  year.  If 
we  can  improve  these  cases  to  this  extent,  the  operation  is  certainly 
indicated,  even  if  the  operation  is  powerless  to  restore  the  kidney  to 
the  normal. 

New  Growths  of  the  Kidney. 

Thirty-eight  per  cent,  of  all  the  reported  cases  of  kidney  tumors 
occurred  in  children  (Doderlein,  Lewi).  The  following  growths  are 
here  considered:  1.  Cysts  of  the  kidney;  2.  Tuberculosis  of  the 
kidney ;  3.  Carcinoma  of  the  kidney ;  4,  Sarcoma  of  the  kidney. 

Cysts  of  the  Kidney.- — Cysts  of  the  kidney  in  children  are  usually 
of  congenital  origin.  They  are  formed  in  the  second  half  of  intra- 
uterine life.  They  are  bilateral,  only  1  in  60  being  unilateral 
(Lejars).  The  kidney  is  made  up  of  greater  and  smaller  cysts. 
The  cystic  formations  may  be  present  to  the  entire  exclusion  of 
kidney  tissue.  The  cysts  may  attain  the  size  of  a  child's  head  and 
seriously  obstruct  delivery.  They  are  of  anatomical  interest  only, 
since  infants  with  such  cysts  present  other  abnormalities  and  die 
soon  after  birth. 

Hydronephrosis.  —  Hydronephrosis  is  either  congenital  or  ac- 
quired. If  acquired,  it  occurs  late  in  childhood.  The  congenital 
form  is  due  to  stenosis  in  some  part  of  the  urinary  tract.  Hydro- 
nephrosis is  as  a  rule  unilateral.  If  it  occurs  after  birth,  it  may 
be  due  to  obstruction  by  calculi  or  to  uric  acid  infarction  of  the  kid- 
ney. The  healthy  kidney  is  physiologically  enlarged.  The  acquired 
form  is  due  to  obstruction  by  calculi  or  to  tumors  pressing  on  the 
ureters.     At  first  the  pelvis  of  the  kidney,   then   its  tissue  is   en- 


PLATE  XXXV 


Sarcoma   of  the    Kidney.     Child   six   years   of  age 
Irregular  contour  of  the  abdominal  tumor. 


DISEASES  OF  THE  KIDNEY.  785 

croached  upon  in  the  gradual  dilatation.  Finally  the  shape  of  the 
kidney  is  lost.  There  is  a  large  fluctuating  tumor  which  may  or 
may  not  be  painful.  When  punctured,  a  fluid  of  low  specific  gravity 
is  withdrawn  which  contains  albumin,  epithelium,  urea,  uric  acid. 
In  some  cases  there  occurs  what  is  known  as  intermittent  hydro- 
nephrosis. The  contents  of  the  tumor  are  emptied  spontaneously, 
but  reaccumulate.  The  diagnosis  rests  on  the  presence  of  a  fluctuat- 
ing tumor  containing  a  fluid,  with  urine  constituents.  Cystoscopy 
may  in  some  cases  reveal  obstruction  of  the  ureters. 

Cysts  must  anatomically  be  differentiated  from  the  condition  of 
hydronephrosis.  Cysts  are  new  growths  (Senator)  ;  in  that  respect 
they  differ  from  the  cystic  condition  of  hydronephrosis.  It  is  not 
possible  clinically  to  differentiate  congenital  cysts  of  the  kidney  from 
congenital  hydronephrosis. 

Sarcoma  of  the  Kidney. — Sarcoma  of  the  kidney  occurs  in  chil- 
dren as  a  primary  growth.  In  the  statistics  of  Rosenstein  and 
Senator  two-thirds  of  the  cases  occur  before  the  tenth  year.  It  is 
more  frequent  in  females.  The  left  kidney  is  more  commonly 
affected.  Sarcoma  occurs  in  the  newly  born  infant.  The  presence 
of  muscle,  bone,  and  cartilage  tissue  in  these  growths  supports  the 
"theory  of  their  congenital  origin  (Jacobi).  The  anatomical  nature 
of  the  growth  varies  widely.  It  may  be  round-celled  or  spindle- 
celled  sarcoma,  a  fibro-sarcoma,  myo-sarcoma,  angio-sarcoma,  mela- 
notic sarcoma,  or  adeno-sarcoma.  There  may  be  metastases.  The 
tumors  sometimes  attain  a  weight  of  fifteen  pounds. 

Sjmiptoms.  — The  symptoms  do  not  differ  materially  from  those  of 
carcinoma  of  the  kidney,  nor  is  sarcoma  of  slower  growth.  In  many 
cases  the  pain,  hasmaturia,  and  tumor  follow  a  traumatism.  Hsema- 
turia  is  not,  as  in  carcinoma  of  the  kidney,  a  constant  symptom.  I 
have  seen  cases  of  both  carcinoma  and  sarcoma  of  the  kidney  in  young 
children  without  haematuria  or  growth  elements  in  the  urine.  Ascites 
is  present  in  more  than  one-half  the  cases  (Lewi). 

Diagnosis. — A  malignant  growth  in  a  child  may  be  surmised  to 
be  a  sarcoma,  since  those  growths  are  more  frequent  in  children  than 
carcinomata.  Swelling  of  the  lymph-nodes  may  be  present  in  sar- 
coma as  well  as  in  carcinoma.  Histological  elements  in  the  urine 
are  rare.  Von  Jaksch  has  mentioned  the  presence  of  small  round 
cells  (sarcoma  cells),  but  their  significance  is  not  as  yet  determined. 
Puncture  for  diagnostic  purposes  is  dangerous,  and  if  performed  at 
all  should  be  done  posteriorly  in  the  lumbar  region  (extraperito- 
neal). In  sarcoma  of  the  kidney,  as  in  all  growths  of  that  organ, 
the  colon  is  pushed  in  front  of  the  growth  (Plate  XXXV.). 

Carcinoma  of  the  Kidney. — Of  449  cases  of  carcinoma  of  the 
kidney  (Rohrer,  Ebstein,  Lachman),  157,  or  almost  35  per  cent., 

50 


786 


DISEASES  OF  KIDNEYS  AND  UBOGENITAL  TBACT. 


occurred  in  children  nnder  the  tenth  3'ear.  Monti  tabulated  50 
cases,  and  found  that  more  than  50  per  cent,  occurred  in  children 
under  the  age  of  two  years.  The  youngest  patient  was  twelve  months 
of  age.  It  is  more  frequent  in  males.  As  a  rule  the  right  kidney 
is  affected.  In  children,  the  growth  is  apt  to  attain  great  size. 
Guillet  found  that  the  average  weight  was  eight  and  one-half  pounds. 
By  reason  of  the  great  weight  of  the  growth,  the  kidney  may  sink 
from  its  normal  position  and  lie  transversely  across  the  vertebral 
column.     The  growth  is  a  primary  one.     The  medullary  carcinoma 


Fig.  178. 


Fig.  179. 


Enlargements  of  the  kidney. 
Anterior   palpable   tumor   beneath   the  Posterior    area    of    flatness    in    the 


livei*. 


lumbar  region,  giving  a  palpable  tumor 
between  the  border  of  the  ribs  and  the 
crest  of  the  ilium. 


is  the  prevailing  type;  the  scirrhous  is  next  in  order  of  frequency. 
The  disease  may  be  secondary  to  carcinoma  of  the  suprarenal  cap- 
sule or  of  the  retroperitoneal  glands.  The  liver,  the  lungs,  and  the 
inguinal  lymph-nodes  may  be  secondarily  involved. 

Symptoms." — The  chief  symptoms  are  pain,  haematuria,  cachexia, 
and  enlargement  of  the  kidney.  Guillet  found  that  hsematuria  was 
the  first  symptom  in  one-half  the  cases.  The  quantity  of  blood 
passed  may  be  very  small,  or  so  great  as  to  amount  to  a  dangerous 
hemorrhage.     The  urine  may  be  red  or  chocolate  colored,  and  may 


DISEASES  OF  TEE  KIDNEY.  787 

contain  clots  of  blood  or  casts  of  the  ureters.  Frequent  micturition 
is  sometimes  an  early  symptom.  In  other  cases  there  is  no  hsema- 
turia,  the  cachexia,  emaciation,  and  tumor  being  the  first  symptoms. 
In  younger  children  the  hsematuria  is  frequently  absent.  The  kidney 
is  in  these  cases  protected  from  traumatism.  The  tumor  is  some- 
times so  great  as  to  cause  displacement  of  the  organs.  In  Fiir- 
bringer's  case  the  heart  was  displaced  to  a  situation  beneath  the 
clavicle.  The  abdomen  is  distended,  and  the  colon  is  pushed  in 
front  of  the  growth  and  is  indicated  by  a  tympanitic  area  at  one  side 
of  the  median  line  of  the  tumor.  On  the  right  side,  the  tumor  appears 
beneath  the  liver,  and  in  narcosis  can  be  felt  in  that  situation  as  a 
distinct  mass.  The  tumor  has  an  uneven  surface.  The  urine  may, 
in  addition  to  blood,  contain  histological  elements  of  the  growth. 
This  does  not  occur  so  frequently  in  carcinoma  of  the  kidney  afe  in 
tuberculosis  of  that  organ. 

Duration. — The  progress  of  the  growth  is  much  more  rapid  in 
children  than  in  adults.  In  the  former  subjects  the  duration  of  the 
disease  is  from  ten  weeks  to  fourteen  months  (Roberts). 

Diagnosis. — In  children,  while  the  diagnosis  of  a  morbid  growth 
of  the  kidnej^  can  be  made,  it  is  not  possible  to  differentiate  between 
the  symptoms  of  carcinoma  and  those  of  sarcoma.  It  cannot  be 
determined,  from  the  symptoms,  whether  the  growth  is  a  simple  car- 
cinoma, an  adeno-carcinoma,  or  an  adeno-sarcoma.  The  symptoms 
of  a  malignant  growth  of  the  kidney  are  pain,  hsematuria,  tumor, 
and  cachexia.  A  cyst  of  the  kidney  may  be  confounded  with  a 
malignant  growth.  Cysts  are  congenital,  and  as  a  rule  bilateral. 
This  is  also  the  case  in  hydronephrosis.  In  the  latter  condition  extra- 
peritoneal puncture  of  the  tumor  may  give  a  fluid  with  urine  con- 
stituents. In  carcinoma  of  the  kidney,  puncture  for  diagnostic  pur- 
poses is  not  devoid  of  danger. 

Tuberculosis  of  the  Kidney. — Tuberculosis  of  the  kidney  is  rarely 
if  ever  primary.  Senator  asserts  that  it  never  occurs  as  a  primary 
lesion.  There  are  pathologically  two  forms — the  miliary  and  the 
cheesy.  The  miliary  form  is  more  frequent  in  children,  the  cheesy 
in  later  life.  In  the  miliary  form,  the  kidney  tissue  is  the  seat  of 
an  eruption  of  miliary  tubercles.  In  the  cheesy  form,  tuberculous 
nodules  may  entirely  replace  the  substance  of  the  organ.  The 
cheesy  form  is  as  a  rule  secondary  to  tuberculosis  of  the  genitals — the 
epididymis  in  boys  and  the  tubes  in  girls.  The  symptoms  do  not 
differ  materially  from  those  of  the  same  condition  in  adults.  In 
the  miliary  form  there  are  no  symptoms.  In  the  cheesy  variety 
there  are  dysuria,  strangury,  vesical  tension,  pain  in  the  region  of 
the  kidney,  emaciation,  and  fever.  The  urine  contains  albumin, 
blood,  epithelium,  and  pus  cells,  and  is  acid  in  reaction.  Tubercle 
bacilli  are  sometimes  found. 


788  DISEASES  OF  KIDNEYS  AND  UBOGENITAL  TBACT. 

Diagnosis. — The  diagnosis  rests  on  the  presence  of  tubercle  bacilli 
in  the  urine,  a  tuberculin  reaction,  an  enlarged  palpable  kidney, 
hsematuria,  and  tuberculosis  of  other  organs — the  genitals  or  the 
lungs. 

Treatment  of  New  Growths  of  the  Kidney.  ^ — The  treatment  of 
new  growths  of  the  kidney  is  within  the  province  of  the  surgeon. 
The  congenital  cysts  are  of  scientific  interest  only.  If  there  is  rea- 
son to  believe  that  there  is  congenital  hydronephrosis  which  is  uni- 
lateral only,  surgical  interference  is  indicated.  Sarcomata  and  car- 
cinomata  should  be  treated  surgically  if  there  is  reason  to  believe 
that  there  are  no  metastases  in  the  liver  or  elsewhere.  Tuberculosis 
of  the  kidney  is  treated  more  from  a  general  standpoint.  If  there 
is  tuberculosis  elsewhere,  palliative  treatment  alone  must  suffice. 
Isolated  tuberculosis  of  one  kidney  is  a  rare  condition  which  necessi- 
tates extirpation  of  the  organ.  If  it  is  impossible  to  determine  the 
proper  treatment,  an  exploratory  operation  is  indicated. 

Perinephritis  and  Paranephritis. — This  condition  is  rare  in  in- 
fancy and  childhood.  It  is  not  always  possible  to  determine  the 
cause.  If  such  is  the  case,  the  disease  is  called  primary.  As  a  rule, 
it  is  secondary  to  traumatism  in  the  lumbar  region,  to  pyelitis,  or  to 
pyelonephritis.  It  may  occur  in  septicopysemic  processes,  and  I 
have  seen  it  follow  the  infectious  diseases,  notably  scarlet  fever.  Of 
166  cases  collected  by  TsTieden,  only  26  occurred  in  children.  One 
case  occurred  in  an  infant  five  weeks  old.  Gibney's  cases  ranged 
from  one  and  a  half  to  ten  years  of  age.  The  condition  is  more 
common  on  the  left  side.  The  pus  may  burrow  behind  the  liver  or 
spleen,  or  find  its  way  downward,  forming  a  mass  simulating  a  cold 
abscess  or  a  perityphlitic  abscess.  It  may  perforate  into  the  pelvis 
of  the  kidney,  the  intestine,  peritoneum,  vagina,  or  diaphragm,  or 
may  pass  along  the  ileopsoas  muscle,  and  find  its  way  to  the  hip, 
and  thus  appear  externally.  The  kidney  may  be  involved  because 
of  its  contiguity  to  the  seat  of  the  process.  Pleuritic  metastases  and 
amyloid  degeneration  may  finally  result. 

Symptoms. — The  symptoms  are  usually  obscure.  The  fever  is 
intermittent  or  remittent.  Young  children  do  not  as  a  rule  complain 
of  pain.  The  first  intimation  of  the  nature  of  the  disease  is  the 
appearance  of  a  swelling  in  the  lumbar  region.  On  bimanual  palpa- 
tion a  tumor  which  is  fixed,  tense,  and  does  not  move  with  respira- 
tion, is  felt  deep  under  the  liver,  in  the  region  of  the  csecum  and 
ascending  colon  on  the  right  side,  or  underneath  the  sj^leen  on  the 
left.  Gibney  has  described  these  cases  and  shown  how  they  may  be 
easily  mistaken  for  cases  of  cold  abscess.  The  thigh  of  the  affected 
side  is  held  in  a  condition  of  semiflexion. 

Treatment. — The  treatment  is  surgical. 


DISEASES  OF  THE  KIDNEY.  789 

Enuresis  Nocturna  and  Diurna. — This  is  a  functional  neurosis  of 
the  bladder  in  which  the  urine  is  passed  involuntarily,  and,  as  a 
rule,  at  night  during  the  first  hours  of  sleep.  It  may,  however,  be 
passed  at  any  time  during  the  night.  Some  patients  have  at  times 
no  control  over  the  bladder  during  the  day  (diurna).  Some  have 
enuresis  every  other  night  or  only  once  or  twice  a  week,  and  others 
suffer  from  the  affection  over  night.  Cases  of  enuresis  should  be 
differentiated  from  those  in  which  there  is  a  complete  paresis  of  the 
sphincter  vesicae.  In  the  latter  case  the  urine  simply  flows  away. 
These  are  cases  of  disease  or  anomaly  of  the  cord  (spina  bifida).  In 
enuresis  the  children  may  in  other  respects  be  in  good  health.  There 
is  frequently  a  nervous  condition.  In  some  cases  there  is  lithiasis 
or  stone  in  the  bladder ;  in  others  the  etiological  factor  is  Oxyuris 
vermicularis,  obstipation,  tumor  of  the  bladder,  or  vulvovaginitis. 
Cystitis  and  adenoids  have  been  regarded  as  causal.  In  the  majority 
of  cases  no  cause  can  be  found.  The  condition  follows  the  exan- 
themata. In  boys  it  usually  disappears  toward  the  sixteenth  year. 
I  have  seen  it  persist  in  girls  into  adult  life.  Its  treatment  becomes 
a  very  serious  problem. 

Diagnosis. — The  diagnosis  is  not  difficult.  The  urine  should  be 
carefully  examined  for  evidences  of  lithiasis,  cystitis,  glycosuria, 
nephritis,  and  nematodes,  and  the  bladder  for  stone.  The  diagnosis 
is  not  made  in  infants  and  very  young  children.  In  the  latter  the 
enuresis  is  often  only  apparent.  They  do  not  know  how  to  indicate 
their  wants. 

Treatment. — The  urine  should  be  passed  before  retiring.  The 
patients  should  take  little  liquid  at  the  evening  meal.  The  foot  of 
the  bed  is  raised  so  that  the  head  is  slightly  lower  than  the  pelvis. 
The  drugs  most  utilized  are  ergot  and  atropine.  The  former  is 
given  in  the  fiuid  extract,  minims  x  to  xxx  (0.6  to  2.0)  t.  i.  d.  Atro- 
pine is  given  before  retiring  in  a  solution  (grain  j  to  §ij  5  0.06  to 
30.),  a  drop  for  every  year  of  the  age  (Watson).  It  is  efficient  in 
many  cases,  but  in  some  children  distinctly  dangerous.  I  had  one 
case  in  which  I  gave  one-half  the  above  dose.  The  child,  five  years 
of  age,  became  slightly  delirious  and  tried  to  walk  out  of  a  window. 
Many  cases  will  improve,  only  to  be  subject  to  relapses.  Marion 
Sims  has  shown  that  enuresis  in  young  girls  may  be  due  to  an  intol- 
erant and  very  small,  contracted  bladder.  In  such  cases,  he  advises 
gradual  dilatation  of  the  bladder  by  injecting  the  organ  with  in- 
creasing quantities  of  an  indifferent  fluid.  If  treated  in  this  way, 
the  bladder  will  eventually  retain  urine.  Most  of  the  cases  resist 
all  methods  of  treatment. 


790  DISEASES  OF  KIDNEYS  AND  UROGENITAL  TRACT. 

DISEASES  OF  THE  UROGENITAL  TRACT. 

Vulvovaginitis  {Urogenital  Blennorrhcea) . — The  term  vulvovagi- 
nitis, or,  as  it  is  now  called,  iTrogenital  blennorrhcea,  refers  to  a  gon- 
orrhoeal  inflammation  of  the  genital  tract  in  children.  Before  de- 
scribing the  condition  it  is  necessary  to  refer  to  catarrhal  conditions 
which  are  not  gonorrhoeal,  and  which  are  present  in  the  normal  state. 

Etiology. — Epstein  has  shown  that  in  the  newly  born  infant  there 
is  a  physiological  and  normal  discharge  from  the  vagina.  It  is  an 
adhesive,  mucoid  discharge  containing  epithelial  cells  and  micro- 
organisms. A  few  days  after  birth,  this  discharge  assumes  a  puru- 
lent and,  in  icterus,  an  icteric  hue.  K'o  leucocytes  are  found  in  the 
discharge.  In  two  weeks  it  ceases  and  the  parts  appear  normal. 
This  form  is  not  gonorrhoeal.  A  second  condition  which  I  have  noted 
in  very  young  children  is  the  result  of  uncleanliness,  lithiasis,  irrita- 
tion caused  by  Oxyuris  vermicularis,  or  masturbation.  The  parts  arc 
reddened  and  eroded,  and  are  bathed  with  an  abnormal  serous  dis- 
charge. There  may  be  a  few  erosions  around  the  introitus.  These 
cases  recover  with  ordinary  care  and  removal  of  the  source  of  irri- 
tation.    Pus  is  rarely  secreted. 

A  second  group  of  cases  occurring  in  young  female  children 
includes  those  of  vulvovaginitis  of  the  simple  catarrhal  type.  These 
have  a  scanty  or  profuse  purulent  discharge  from  the  vagina,  vulva, 
and  urethra,  which  presents  clinically  all  the  features  of  the  specific 
gonorrhoeal  group,  but  is  not  gonorrhoeal.  The  condition  is  not  of 
infrequent  occurrence.  The  urethral  orifice  is  swollen  and  red.  The 
hymen  is  also  swollen  and  inflamed.  The  discharge  is  thin  and 
milky,  or  greenish  and  viscid.  Microscopically,  it  shows  in  the  pus- 
cells  bacteria  and  diplococci  in  groups,  but  these  do  not  show  either 
by  culture  or  on  staining  the  characteristics  of  the  gonococci.  The 
history  of  such  discharges  is  singularly  similar  to  that  of  the  gonor- 
rhoeal form.  Urination  is  painful,  and  the  discharge  persists  even 
under  careful  treatment.  In  one  case  of  this  kind  I  have  seen  an 
inguinal  bubo.  The  catarrh,  like  the  gonorrhoeal  form,  affects  the 
urethra,  vulva,  vagina,  and  cervix  uteri.  I  am  convinced  that  the 
discharge  is  infectious  and  communicable  from  one  child  to  another. 
It  may  last  for  months  and  again  recur.  Its  exact  etiology  is  still 
unknown.  Uncleanliness,  infection  from  a  vaginal  discharge,  maras- 
mus, the  infectious  diseases,  or  frail  health  may  be  the  cause. 

Cases  of  urogenital  blennorrhoea  have  been  described  by  Pott, 
van  Dusch,  Spaeth,  Cahen-Brach,  Epstein,  and  others. 

Occurrence. — This  affection  may  occur  in  newly  born  infants  (Ep- 
stein) or  in  older  infants  and  children.  Epidemics  may  occur  in  hos- 
pitals (Frankel).      The  avenue  through  which  the  disease  is  conveyed 


DISEASES  OF  THE  UROGENITAL  TBACT. 


791 


is  still  unknown.  It  occurs  in  all  walks  of  life.  In  some  cases  there 
is  a  history  of  the  child's  having  slept  with  the  mother.  In  others, 
there  is  no  such  history.  I  have  sometimes  obtained  a  history  of 
an  abnormal  attempt  at  coitus  between  boys  and  girls,  the  boys 
having  suffered  at  the  time  from  gonorrhoea.  Such  cases  are,  how- 
ever, exceptional.  The  exciting  cause  is  the  gonococcus  (ISTeisser) 
(Fig.  180).  This  micro-organism  has  been  found  in  the  discharges 
of  all  these  cases,  and  cultivated  (Koplik,  Heiman,  WoUstein). 

Symptoms. — There  is  a  thick,  viscid,  purulent,  greenish  or  yel- 
lowish discharge  from  the  vagina,  which  bathes  the  parts  and  dries 
in  crusts  on  the  labia.  The  opening  of  the  urethra  is  reddened  and 
swollen.  There  is  a  discharge  from  the  urethra.  Micturition  is 
painful.     In  some  cases  there  are  slight  swellings  of  the  inguinal 

Fig.  180. 


Gonococci  in  vaginal  discliarge.     Cover-glass  spread.     Photomicrograph,     x  1000. 


lymph-nodes.  If  the  speculum  which  is  used  for  the  male  urethra 
is  introduced  into  the  vagina  (Tuttle's  urethral  speculum),  it  is  seen 
that  the  purulent  discharge  is  present  in  the  folds  of  the  mucous 
membrane  of  the  vagina.  The  cervix  uteri  also  contains  a  drop  of 
pus.  Thus  the  whole  genital  tract  is  involved.  Some  children  com- 
plain of  pain  over  the  lower  part  of  the  abdomen.  On  examination, 
this  is  found  to  be  pelvic,  and  is  probably  due  to  inflammatory  reac- 
tion of  the  tissues  about  the  uterus  and  vagina. 

Complications  and  Course, — The  course  of  the  disease  is  quite 
tedious,  and  may  occupy  eight  weeks,  three  months,  or  more.  The 
discharge  may  abate,  only  to  return  in  its  original  severity. 

Peritonitis  has  in  rare  cases  been  reported  as  a  complication  of 
this  form  of  vulvovaginitis.     It  may  prove  fatal.     I  have  met  two 


792  DISEASES  OF  KIDNEYS  AND  USOGENITAL  TEACT. 

cases.  Hunner  and  Harris  recently  reported  a  fatal  case  in  a  girl 
ten  years  of  age.  They  collected  5  other  cases  from  the  literature 
occurring  in  children.  Pelvic  peritonitis  occurred  in  2  of  my  cases 
with  the  usual  signs  of  pain  and  fever.  Both  cases  made  a  good 
recovery. 

Hartley  and  the  writer  have  reported  cases  of  arthritis  complicat- 
ing vulvovaginitis  in  children.  My  cases  occurred  in  the  first  and 
second  weeks  of  the  disease.  In  one  case,  only  one  joint  was  affected ; 
in  another,  two.     Both  recovered  without  suppuration. 

Gonorrhoeal  conjunctivitis  may  result  from  careless  infection  of 
the  eyes.  I  have  had  only  2  cases  in  which  the  patients  complained 
of  praecordiah  pain.  In  neither  were  there  active  symptoms  of  endo- 
pericarditis,  but  there  is  no  reason  why  it  might  not  occur  in  children, 
as  in  adults. 

Sanger  at  one  time  traced  a  connection  between  sterility  in  later 
life  and  attacks  of  this  disease  in  childhood. 

Treatment.- — Prophylaxis  is  of  great  importance.  A  child  affected 
with  the  disease  should  not  be  allowed  to  sleep  with  other  children. 
The  toilet  appliances  should  not  be  used  by  other  children.  The 
parents  should  be  carefully  enlightened  concerning  the  infectious 
nature  of  the  affection  and  the  great  danger  to  the  eyesight  should 
infection  of  the  eyes  occur.  The  hands  of  the  patient  should  be  kept 
scrupulously  clean.  In  institutions  the  patients  should  be  strictly 
isolated.  The  vulva  should  be  kept  covered  with  a  pad  of  absorbent 
gauze,  and  a  diaper  should  be  worn  over  this  to  prevent  the  dis- 
charge from  soiling  the  clothes.  In  the  acute  stage,  the  vagina  should 
be  irrigated  with  a  glass  catheter  or  a  Skene  urethral  catheter  twice 
daily.  The  solution  should  be  at  a  temperature  of  108°  F.  (42.2° 
C).  The  irrigating  solutions  should  be  either  a  2  per  cent,  solution 
of  acetate  of  aluminum  or  a  1 :  2000  or  a  1 :  500  solution  of  nitrate 
of  silver.  If  the  silver  or  aluminum  solution  is  irritating  a  simple 
saturated  solution  of  boric  acid  may  be  used. 

I  have  found  a  25  per  cent,  solution  of  argwrol  quite  effective  in 
diminishing  the  severity  of  the  discharge.  The  vagina  is  first  irri- 
gated with  boracic  acid  and  then  with  the  solution  of  argyrol.  In  the 
subacute  stage  the  vagina  is  painted  every  other  day  with  a  5  or  10 
per  cent,  solution  of  nitrate  of  silver.  A  Tuttle  urethral  speculum 
is  used  for  the  purpose.  If  the  child  is  intractable,  it  is  impossible 
to  do  this  without  the  use  of  an  ana?sthetie,  which,  however,  seems 
scarcely  justifiable.  I  have  cured  these  cases  with  rest  in  bed  and 
irrigations.  I  have  tried  the  bougie  treatment  and  the  protargol  and 
permanganate  of  potassium  irrigations,  but  have  found  the  treatment 
above  described  preferable. 


DISEASES  OF  THE  UROGENITAL  TBACT.  793 

Urethritis  in  Male  Children. — Simple  urethritis  of  the  anterior 
portion  of  the  urethra  occurs  in  infants  and  young  children.  It  is 
caused  either  by  unnatural  interference  with  the  parts  or  infection. 
It  is  not  gonorrhoeal.  The  meatus  is  slightly  red  or  the  parts  are 
agglutinated  with  dried  pus.  On  pressure,  a  drop  of  pus  exudes 
from  the  urethra.  There  is  ardor  urinse,  due  to  a  slight  fissuration 
of  the  meatus.  The  affection  is  easily  cured  by  attention  to  clean- 
liness. An  alkali,  such  as  citrate, of  potassium,  is  given  in  very  small 
doses,  to  alleviate  the  ardor  urinre. 

Gonorrhoea  occurs  in  male  infants  and  boys,  and  is  the  result  of 
direct  infection.  The  symptoms  are  much  the  same  as  in  adults, 
except  that,  as  a  rule,  there  are  no  complications.  Balanoposthitis 
and  lymphadenitis  may  occur,  also  epididymitis,  and  rarely  orchitis. 
Bokai  reports  cases  of  stricture. 

Cystitis,  Pyelitis,  and  Pyelonephritis. — This  affection,  which  is 
peculiar  to  infants  and  children,  was  first  called  coli-cystitis  by 
Escherich,  in  view  of  the  bacterial  causation  of  the  disease.  The 
question  af  nomenclature  is  complex  in  view  of  the  fact  that  Amer- 
ican (Holt)  and  English  authorities  designate  this  affection  by  the 
term  pyelitis,  whereas  the  Germans  speak  of  cystitis.  The  question 
is  one  of  origin  of  the  disease  and  from  my  own  experience  I  think 
it  but  proper  to  call  the  disease  cystitis,  inasmuch  as  it  seems  to  me 
most  of  the  cases  originate  from  local  infection  in  the  bladder.  The 
infection  may  then  travel  up  the  ureters  and  involve  the  pelvis  of 
the  kidney  and  finally  the  kidney  itself  may  become  involved  in  the 
suppurative  process  and  there  results  a  pyelo-nephritis.  There  are, 
however,  certain  rare  cases  which  cannot  be  accounted  for  in  this 
simple  manner,  but  which  may  begin  in  the  pelvis  of  the  kidney, 
travel  down,  and  subsequently  involve  the  bladder.  If  they  do  occur 
the  infection  takes  place  through  the  blood,  for  in  no  other  way  can 
we  account  for  such  a  course  of  the  infection. 

Cystitis  is  a  common  affection  of  infancy  and  childhood.  Esch- 
erich called  attention  to  it  and  cases  have  been  described  by  Trumpp, 
Holt  and  others. 

Etiology. — The  most  frequent  cause  of  cystitis  is  the  Bacillus  coli 
communis,  as  first  demonstrated  by  Escherich,  though  other  bac- 
teria, such  as  the  Gonococcus,  the  Staphylococci,  Streptococci  and 
typhoid  bacilli  may  all  cause  cystitis.  The  direct  inciting  causes 
are  exposure  to  cold  or  any  inflammation  about  the  urethra  or  vulva 
in  the  female.  It  is  found  to  complicate  the  infectious  diseases, 
such  as  scarlet  fever,  measles,  pneumonia,  diphtheria,  and  influenza. 
A  large  percentage  of  cases  certainly  complicate  some  disturbance 
of  the  functions  of  the  intestines.  Thus  a  large  number  of  my  cases 
complicated  or  were  preceded  by  some  form  of  quasi-enteric  infection 


794 


DISEASES  OF  KIDNEYS  AND  UBOGENITAL  IBACT. 


and  diarrhoea.  This  corresponds  with  Trumpp's  experience.  In 
such  cases  the  theory  holds  that  through  uncleanliness  the  bladder 
has  become  infected  through  the  urethra.  This  mode  of  infection 
will  not  hold  in  boys  in  whom  the  urethra  is  long  and  the  infection 
in  them  is  more  probably  systemic  through  some  lesion  in  the  mucous 
membrane  of  the  intestine. 

Frequency. ^Of  36  of  my  own  cases  only  7  occurred  in  male  chil- 
dren, thus  showing  the  predominance  of  the  affection  in  the  female 
sex.  This  can  only  be  accounted  for  by  the  ease  with  which  infec- 
tion travels  from  the  introitus  vaginae  into  the  urethra  and  bladder 
in  the  female.  Of  the  37  cases,  20,  more  than  half,  occurred  in 
infants  under  one  year  of  age,  showing  the  susceptibility  of  infants 
who  are  still  using  diapers.  Only  5  cases  occurred  after  the  fifth 
year.     One  case  occurred  in  a  newborn  infant  ten  days  old. 


Fig.  181. 


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Churacteristlc  curve  of  temperature  in  cystitis  or  pyelitis  of  infancy. 

Symptoms. — The  symptoms  of  cystitis  in  infants  and  children 
are  not  sufficiently  characteristic  to  direct  attention  to  the  aifection 
unless  the  physician  bears  the  possibility  of  its  occurrence  in  mind 
in  every  case  of  fever  of  obscure  origin.  The  main  features  are 
fever,  frequency  of  urination,  pain  on  urination,  recurrence  of  chills, 
and  staining  the  diapers  in  young  infants  a  peculiar  yellowish  tinge. 

Pever. — The  characteristic  of  the  fever  is  that  it  is  high  with 
remissions  to  the  normal  (Fig.  181).  It  may  be  104°  to  106°  and 
still  the  infant  may  not  appear  to  be  very  much  prostrated.  With  the 
fever  there  is  the  occurrence  of  chills.  The  patient  becomes  blue  and 
pale  and  in  some  cases  there  may  be,  in  susceptible  infants  and  in 
the  newborn,  convulsions.  The  fever  lasts  for  days  or  weeks  and 
even  when  the  affection  is  improving  there  may  be  recurrences. 


DISEASES  OF  THE  UROGENITAL  TRACT.  795 

Pain. — I  have  obtained  a  distinct  history  of  pain  in  urination, 
the  urine  being  passed  with  tenesmus  and  in  small  quantities. 

Anaemia. — Quite  characteristic  of  all  cases  of  cystitis  in  infancy 
is  a  marked  and  increasing  anaemia  after  the  disease  has  lasted  for 
a  period  of  one  or  two  weeks.  This  ansemia  is  quite  easy  of  recog- 
nition and  after  having  seen  a  number  of  these  cases  this  striking 
feature  in  infants  who  have  a  febrile  movement  of  obscure  origin 
will  direct  one's  attention  to  an  examination  of  the  urine.  With  .the 
anaemia  there  is  loss  of  weight  and  the  musculature  loses  its  tone. 
There  may  also  be  disturbances  of  the  functions  of  the  intestine,  as 
evinced  by  abnormal  movements. 

Urine.- — The  urine  is  acid  in  reaction,  turbid,  contains  flocculi  of 
fibrin,  pus,  and  a  small  amount  of  albumin.  Microscopically  it 
contains  a  large  quantity  of  pus-cells,  some  bladder  epithelium;  in 
severe  cases  renal  epithelium,  hyaline,  epithelial  casts,  and  blood, 
and  Bacterium  coli  communis  or  other  bacteria  mentioned. 

Diagnosis. — The  diagnosis  is  made  from  the  presence  of  fever 
where  every  other  cause  has  been  excluded,  the  history  of  chills,  the 
progressive  anaemia,  all  in  the  face  of  a  history  of  bowel  disturbance 
or  grippe  should  lead  to  an  inquiry  into  the  condition  of  the  urine. 
In  many  infants  who  have  been  trained  the  urine  can  be  easily 
obtained  by  placing  them  on  the  commode.  In  other  cases  the  sim- 
plest procedure  is  to  catheterize  the  infant.  The  appearance  of  the 
urine  even  before  microscopic  examination  will  lead  to  the  diagnosis. 

In  all  cases  of  cystitis  in  infants  and  children  the  kidneys 
should  be  carefully  palpated  in  order  to  discover  an  involvement  of 
these  organs.  If  they  are  involved  they  can  be  distinctly  felt 
through  the  abdominal  walls  as  markedly  enlarged  and  tender.  In 
such  a  case  the  diagnosis  of  a  complicating  pyelitis  or  pyelonephritis 
is  warranted. 

Course  and  Termination. — A 'majority  of  my  cases  have  recovered 
within  the  short  time  of  one,  two  or  more  weeks ;  others  have  not  had 
such  a  favorable  ending,  especially  cases  whose  onset  has  been  over- 
looked and  the  diagnosis  delayed  for  weeks.  In  these  the  urine  con- 
tinued to  contain  pus  and  casts  for  months  with  no  prospect  of  any 
clearing  up  of  the  urine  under  energetic  management.  The  infants 
were  not  at  all  badly  affected  by  the  disease,  but  increased  in  weight 
and  their  color  improved.  In  the  cases  which  I  saw  in  older  chil- 
dren and  studied  in  the  hospital  mixed  infection  of  the  urine  occurred 
after  a  time  and  the  reaction  became  alkaline  with  the  presence  of 
Staphylococci  and  Streptococci  in  the  urine.  Among  my  cases  there 
was  one  in  a  newborn  infant  which  developed  bacillaemia  and  finally 
a  meningitis  due  to  coli  bacilli.  Here  the  convulsions  were  repeated 
with  every  appearance  of  a  chill.  The  child  did  not  die,  but  recov- 
ered, a  hydrocephalic  idiot. 


796  DISEASES  OF  KIDNEYS  AND  USOGENITAL  TBACT. 

In  one  case  of  an  infant  six  months  of  age,  pyelitis  developed 
with  snppnrative  nephritis  and  the  kidneys  after  death  were  very 
much  enlarged  and  studded  with  abscesses,  being  similar  to  a  sur- 
gical kidney.  Finally  another  case  proved  fatal  through  pyelitis 
and  septic  nephritis.  Thus  we  cannot  say  what  the  outcome  of  any 
case  may  be  before  treatmeut,  but  should  warn  those  cojacerned  of 
the  seriousness  of  the  prognosis.  Any  involvement  of  the  kidney 
clouds  the  prognosis  unless  the  infection  of  the  kidney  is  only 
temporary. 

Treatment. — There  must  be  a  large  number  of  cases  which  run  a 
mild  course  and  which  recover  with  very  little  but  symptomatic 
treatment.  There  are  infantile  cases  in  which  the  diagnosis  has 
been  overlooked.  The  dangers  which  threaten  have  been  dwelt 
upon.  The  treatment  consists  in  placing  the  bowels  in  a  correct  con- 
dition, and  administering  salol  or  urotropin.  Infants  will  take  two 
or  three  grains  of  either  drug  without  any  danger  three  times  daily. 
If  urotrojjin  is  not  well  borne  and  gives  rise  to  diarrhoea  or  bloody 
urine,  salol  is  substituted.  An  alkaline  water  is  given  in  the  food, 
the  so-called  Poland  water  being  the  most  available.  In  convales- 
cence citrate  of  potash  is  used,  grs.  v,  three  times  daily.  Saccharine 
is  given  in  older  children  as  in  the  adult.  The  question  of  bladder 
irrigation  arises.  My  experience  in  acute  cases  is  that  irrigation  of 
the  bladder  with  various  solutions  is  unsatisfactory.  In  the  chronic 
and  subacute  cases  they  have  seemed  in  my  hands  to  have  availed. 
The  bladder  is  washed  out  once  a  day.  In  children  it  is  a  simple 
and  harmless  procedure  if  utmost  cleanliness  is  observed.  In  those 
eases  in  which  the  kidney  had  become  involved  surgery  in  my  hands 
has  not  held  out  any  encouragement,  though  if  marked  pyelonephrosis 
occurs  the  surgical  indication  is  evident.  Treatment  should  not  be 
suspended  until  it  is  certain  that  the  urine  has  cleared  and  is  in  a 
normal  condition. 

Bacilluria. — Bacilluria  is  a  peculiar  condition  observed  b}^  Esch- 
erich,  Trumpp,  Box  and  others,  which  differs  from  the  condition 
ju&t  described  in  that  the  urine  does  not  contain  pus  but  only  bacilli 
coli.  It  is  a  form  of  bacteriuria.  This  condition  may  precede 
the  development  of  cystitis  and  pyelitis.     It  is  uncommon. 


SECTION  XV. 

DISEASES  OF  THE  NERVOUS  SYSTEM. 

CONVULSIONS  IN  INFANCY  AND  CHILDHOOD. 

Eclampsia  Infantum. — Convulsions  are  a  series  of  violent  clonic 
contractions  of  a  number  of  muscles,  or  of  the  muscles  supplying  one 
limb.  There  is  always  more  or  less  of  a  tonic  spasm  at  first.  The 
convulsions  are  paroxysmal  and  accompanied  by  a  loss  of  conscious- 
ness. In  this  section  the  acute  convulsions  of  infancy  and  childhood 
are  especially  considered,  and  will  be  differentiated  from  certain 
spasmodic  affections,  such  as  laryngismus,  tetanus,  and  epilepsy, 
which  are  accompanied  by  spasms,  though  classed  by  some  as  forms 
of  convulsions. 

Classification. — Convulsions  of  infancy  may  be  classified  as  those 
which  are  primary  or  idiopathic,  and  those  which  are  secondary, 
reflex,  or  symptomatic.  In  the  first  rubric  are  included  the  con- 
vulsions which  occur  spontaneously,  or  after  some  sensory  irritation, 
very  often  of  an  obscure  origin,  such  a&  epileptic,  hystero-epileptic 
seizures,  and  tic.  With  increasing  knowledge  this  class  is  gradually 
becoming  more  and  more  limited. 

In  the  second  class  the  symptomatic  or  reflex  convulsions  are 
included:  (a)  the  cases  which  follow  abnormal  conditions  of  the 
circulation  in  the  brain,  such  as  anaemia  or  hypersemia;  (&)  con- 
vulsions which  occur  at  the  outset  of  infectious  diseases;  (c)  convul- 
sions which  are  caused  by  disturbance  of  metabolism,  and  which 
occur  at  the  outset  or  in  the  course  of  certain  diseases  in  which  toxins 
are  thrown  into  the  blood;  (d)  those  which  follow  some  peripheral 
irritation,  such  as  occurs  in  a  reflex  manner  in  wounds,  burns,  etc., 
or  directly  reflex,  as  in  meningitis,  tumors  of  the  brain,  hydroceph- 
alus, brain  compression,  poisons  circulating  in  the  blood  (lead). 

Occurrence. — The  acute  convulsions  of  infancy  and  childhood  are 
symptomatic,  and  occur  chiefly  during  the  first  half  year  of  life. 
Fully  four-fifths  of  the  cases  occur  before  the  end  of  the  second  year 
of  life.  They  are  uncommon  after  this  period;  but  a  child  who  has 
had  convulsions  of  the  symptomatic  type  in  infancy  is  likely  to  have 
a  recurrence  of  the  convulsions  up  to  the  seventh  year  of  childhood. 

Etiology. — The  occurrence  of  convulsions  necessitates  not  only 
the  presence  of  an  exciting  agent  or  irritating  substance,  but  there 
must  exist  a  certain  constitutional  disposition  or  predisposition  to 

797 


798  DISEASES  OF  TEE  NESVOUS  SYSTEM. 

convulsions,  which  may  be  hereditaiy.  Soltmann  has  shown  that  in 
the  newborn  animal  irritability  of  the  motor  nerves  is  almost  nil, 
and  that  of  the  sensory  nerves  much  below  what  is  attained  in  later 
life.  In  the  newborn,  also,  there  is  an  absence  of  reflex  inhibition, 
and  the  brain  lacks  volition ;  in  other  words  there  is  an  absence  of 
the  psycho-motor  centres.  The  inhibitory  centres  do  not  develop  in 
parallel  lines  with  the  peripheral  irritability  of  the  sensory  nerves. 
Reflex  irritability  is  very  much  diminished  at  the  outset,  but  in- 
creases later,  becoming,  at  a  certain  period  of  infancy,  above  what  is 
found  in  the  adult.  The  musculature  of  the  infant,  on  account  of 
the  instability  of  the  nervous  centres,  can  be  thrown  into  tetanic  con- 
traction by  the  least  irritation.  This  period  of  increased  reflex  irri- 
tability of  the  nervous  centres  has  been  placed  experimentally  by  Solt- 
mann at  from  the  fifth  to  the  eleventh  month  of  infancy,  thus  corre- 
sponding with  what  is  found  in  the  human  subject  clinically. 

Although  the  theories  of  Soltmann  are  not  wholly  endorsed  by 
other  observers,  it  remains  true  that  in  infancy  the  inhibitory  centres 
are  not  fully  active,  that  the  psychomotor  centres  are  absent,  and 
that  this  is  a  period  of  increased  reflex  irritability  of  the  peripheral 
nerves.  In  a  causal  sense,  not  only  does  this  increased  reflex  irri- 
tability predispose  to  acute  convulsions  in  infancy  and  childhood,  but 
with  it  there  is  a  hsematogenous  toxic  element  especially  active  at 
this  period  of  life. 

In  infancy  we  have  also  the  hereditary  predisposition  to  neuroses, 
and  tendencies  derived  from  neurasthenic,  alcoholic,  syphilitic,  and 
tuberculous  parents. 

It  seems,  therefore,  that  causal  agents  of  acute  convulsions  in 
infancy  and  childhood  are  principally  periodical  toxins,  such  as  are 
present  in  the  circulation  (hsematogenous)  at  the  outset  of  infectious 
diseases,  as  acute  amygdalitis,  exanthemata,  typhoid  fever,  malaria, 
influenza,  pertussis,  mumps — all  of  which  may  be  ushered  in  with 
a  convulsion. 

The  explosion  appears  to  be  caused  b}^  the  initial  effect  of  the 
toxins  and  temperature  on  the  ganglion-cell.  Convulsions  sometimes 
take  the  place  of  the  initial  chill  in  pneumonia  and  malarial  fever. 

The  disturbances  of  metabolism  which  may  cause  toxins  to  be 
thrown  into  the  circulation  occur  in  connection  with  gastro-enteric 
disease  of  any  kind  or  with  indiscretions  in  diet.  Children  who  eat 
an  excessive  quantity  of  meat  are  particularly  subject  to  these  seiz- 
ures. In  addition  to  the  above  exciting  agents  we  have  mentioned 
also  disturbances  of  the  circulation  which  may  cause  convulsions,  and 
these  are  found  in  connection  with  pertussis,  bronchitis,  and  heart 
disease.  In  these  affections  there  is  an  accumulation  of  carbonic 
acid  gas  in  the  circulation,  which  is  the  exciting  agent  of  the  initial 


CONVULSIONS  IN  INFANCY  AND  CHILDHOOD.  799 

explosion;  and,  finally,  we  have  as  causes  of  convulsions  the  direct 
effect  of  mineral  poisons,  such  as  lead,  circulating  in  the  blood. 

Convulsions,  according  to  some  authors,  may  be  caused  by  the 
presence  of  alcohol  in  the  mother's  milk.  This  is  a  very  question- 
able cause  of  convulsions.  Rarely,  convulsions  may  be  caused  by 
reflex  irritation  of  a  foreign  body  in  the  stomach,  or  by  overdisten- 
tion  of  the  stomach  during  stomach-washing,  an  instance  of  which  the 
author  has  seen ;  by  burns,  wounds,  effects  of  cold,  incarceration  of  a 
hernia.  Retention  of  urine  may,  by  reflex  peripheral  irritation, 
cause  convulsions.     The  toxic  form  of  convulsions  occurs  in  ursemia. 

Dentition  is  frequently  mentioned  among  the  causes  of  convul- 
sions. Since  dentition  in  a  normal  infant  is  devoid  of  symptoms, 
it  is  straining  a  theory  to  ascribe  convulsions  to  irritation  of  the 
trigeminal  branches.  The  acceptation  of  this  dentition  theory  might 
lead  one  to  overlook  some  serious  condition,  of  which  the  first  indica- 
tion is  an  eclamptic  seizure. 

Under  the  heading  of  circulatory  disturbances  might  further  be 
mentioned  an  acute  cerebral  anaemia,  caused  by  severe  hemorrhage, 
which  may  give  rise  to  a  convulsion.  Such  convulsions  are  hardly 
included  under  the  conception  of  infantile  convulsions  of  the  acute 

type. 

Pathogeny. — The  pathogeny  of  convulsions  in  infancy  and  child- 
hood is  the  same  as  in  the  adult.  The  explosions  are  due  to  irrita- 
tion of  the  centres  in  the  ponto-bulbar  junction,  or  in  the  area  of 
Rolando  (Hughlings  Jackson).  The  starting-point  of  every  convul- 
sion is  a  ganglion-cell.  It  is  not  known  whether  the  inherited  neu- 
rotic tendencies  already  mentioned  are  powerful  factors  during 
infancy,  or  whether  alcoholism  or  epilepsy  in  the  family  are  active 
in  causing  convulsions  of  the  purely  acute  type  in  infancy.  Rachitic 
children,  however,  according  to  Kassowitz  and  Elsasser,  are  pecu- 
liarly subject  to  convulsions,  because  the  cranial  bones  are  the  seat 
of  hypersemia  and  softening.  The  motor  areas  adjacent  to  these 
points  of  hypersemia  and  softening  are  supposed  to  be  in  a  state  of 
constant  irritability. 

Kussmaul  and  Tenner  have  demonstrated  that  there  is  an  acute 
ansemia  of  the  brain  during  convulsions.  On  the  other  hand,  it  often 
happens  that  the  convulsion  is  the  cause  of  the  bursting  of  a  cerebral 
vessel.  In  such  cases  the  signs  of  cerebral  surface  hemorrhage  are 
present  at  autopsy.  In  other  cases,  although  death  has  occurred 
during  a  convulsion,  nothing  is  found  postmortem  but  an  oedema  of 
the  brain  substance,  of  doubtful  origin. 

Symptoms. — The  majority  of  convulsive  seizures  in  infants  and 
children  are  single.  In  certain  cases  the  convulsions  are  repeated 
and  extend  over  a  prolonged  period.     The  latter  are  not  cases  of 


800  DISEASES  OF  THE  NEBVOUS  SYSTEM. 

simple  acute  infantile  convulsions.  The  symptoms  of  acute  eclamp- 
sia are  sometimes  so  very  slight  as  to  he  scarcely  noticeable.  A  very 
observant  mother  v^^ill  see  a  slight  tvs^itching  of  the  lips  and  eyelids, 
a  momentary  turning  of  the  eye  and  cessation  of  breathing,  or  a 
momentary  spasm  of  the  whole  trunk.  The  expression  "  internal 
convulsion,"  so  frequently  heard,  evidently  denotes  these  slight 
eclamptic  seizures.  The  genuine  convulsion  comes  on  without  pre- 
monitory symptoms.  There  is  a  momentary  spasm  of  the  body,  the 
head  turns  to  one  side  and  upward,  and  there  is  a  corresponding 
upward  direction  of  the  eye.  Then  follow  a  series  of  clonic  spasms 
involving  the  upper  and  lower  extremities,  and  lasting  for  some  time. 

The  hands  are  clenched,  the  forearms  flexed,  the  body  rigid, 
the  lower  extremities  extended,  the  head  thrown  back.  This  tonic, 
momentary  spasm  is  followed  by  a  clonic  spasm,  beginning  in  the 
muscles  of  the  face  and  involving  those  of  the  trunk  and  extremities. 
The  teeth  are  set,  the  tongue  is  protruded  and  may  be  bitten.  There 
are  cyanosis  and  frothing  at  the  mouth.  The  respirations  are  short 
and  hissing,  the  pulse  is  imperceptible,  and  at  the  outset  of  the  con- 
vulsion the  heart  becomes  slow  and  irregular.  A  cold  perspiration 
bathes  the  surface.  The  convulsive  seizure  may  be  momentary,  may 
last  a  few  minutes  to  a  quarter  of  an  hour,  or  one  spasm  may  be  fol- 
lowed rapidly  by  others  extending  over  the  same  period  of  time. 
Toward  the  termination  of  the  convulsive  spasm  the  clonic  contrac- 
tions become  less  frequent ;  the  child  passes  into  a  sleep  or  coma.  In 
some  cases  the  clonic  spasms  may  be  limited  to  one  side  of  the  body. 

The  child  may  be  in  a  state  of  eclampsia  for  an  hour,  after  which 
it  may  pass  into  the  comatose  state.  The  coma  may  be  momentary 
or  may  merge  into  a  sleep  of  variable  duration.  The  end  of  the 
convulsive  spasm  is  signalized  by  muscular  clonic  spasms  decreasing 
in  severity,  until  finally  a  long-drawn  inspiration  ends  the  attack. 

Diagnosis. — It  is  very  important  to  be  able  to  distinguish  between 
the  various  forms  of  convulsive  seizures.  Those  occurring  imme- 
diately after  or  within  a  few  hours  or  days  of  birth  have  a  different 
significance  from  those  just  described.  They  may  be  caused  by  cere- 
bral hemorrhage,  and  there  will  be  symptoms  after  the  convulsions, 
such  as  palsies,  contracture,  difficulty  in  deglutition,  and  prolonged 
coma.  In  these  cases  the  convulsions  are  repeated.  Atelectasis  of 
the  congenital  variety  may  cause  convulsions.  The  patients  have 
slight  or  marked  cyanosis,  and,  in  the  intervals,  increase  of  respira- 
tions and  signs  of  bronchitis  and  collapse  of  the  lung. 

Tumor  and  abscess  of  the  brain,  and  meningitis,  both  cerebro- 
spinal and  tuberculous,  may  be  ushered  in  by  convulsions.  In 
tumor,  the  convulsions  are  limited  to  the  area  in  which  the  tumor  or 
abscess  is  localized.     In  forms  of  meningitis,  there  will  be  the  symp- 


CONVULSIONS  IN  INFANCY  AND  CHILDHOOD.  801 

toms  of  that  disease.  Drugs  and  poisons  may  give  rise  to  convul- 
sions. The  history  of  such  cases  v^ill  be  of  service.  Cases  of  tetany 
and  tetanus  have  convulsions  in  the  course  of  the  disease.  In  tetany 
there  may  be  several  convulsions  in  the  course  of  twenty-four  hours. 
Tonic  spasm  is  the  chief  feature  of  the  convulsion  in  tetany  and 
tetanus.  The  clonic  form  distinguishes  acute  convulsions.  In 
tetanus  there  is  slowly  increasing  opisthotonos.  In  tetany  the  body 
may  be  lax  in  the  interval,  but  there  are  rare  cases  of  tetany  which 
resemble  tetanus  in  that  there  is  rigidity  in  the  intervals  between  the 
spasms.  In  tetany  the  extremities  have  a  characteristic  position. 
In  some  cases  of  simple  acute  infantile  convulsions,  an  increased  irri- 
tability of  the  nerves  and  muscles  to  mechanical  stimulus  remains 
for  days  after  the  paroxysms.  The  Chvostek  and  Trousseau  phe- 
nomena are  found.  Some  authors  have  regarded  these  cases  as  cases 
of  latent  tetany.  The  diagnosis  of  the  various  epileptiform  seizures 
will  be  considered  in  the  section  devoted  to  that  subject. 

Prognosis. — The  prognosis  of  acute  infantile  convulsions  is  gen- 
erally good,  but  since  death  has  occurred  in  these  seizures,  as  well  as 
cerebral  hemorrhage,  caution  should  always  be  exercised  in  predict- 
ing the  immediate  outcome.  The  patient  having  been  once  tided 
over  the  initial  paroxysm,  it  may  be  confidently  expected  that  it  will 
not  be  repeated.  In  the  presence  of  fever,  it  cannot  be  predicted 
what  affection  may  follow  the  seizure.  Primary  seizures  should 
not  be  regarded  as  forerunners  of  epilepsy.  Many  infants  and  chil- 
dren affected  with  convulsive  seizures  pass  through  later  life  without 
any  sign  of  that  disease. 

Treatment. — The  seizure  is  frequently  over  before  the  physician 
arrives.  If  such  is  the  case  and  the  infant  is  in  the  stage  of  stupor, 
it  should  not  be  disturbed  unless  there  is  high  fever  or  a  history  of 
the  patient's  having  eaten  some  irritating  substance.  It  often  hap- 
pens that  the  paroxysm  supervenes  in  the  presence  of  the  physician. 
The  patient  is  placed  on  a  bed,  the  clothes  loosened,  and  a  small 
object,  such  as  the  handle  of  a  tooth-brush,  placed  between  the  teeth 
to  save  the  tongue  from  injury.  ISTothing  further  is  needed.  The 
paroxysm  is  as  a  rule  over  in  three' minutes  at  most.  If  it  persists 
or  is  immediately  succeeded  by  another,  the  patient  is  placed  in  a 
warm  bath,  after  which  a  few  drops  of  chloroform  are  administered 
by  inhalation  to  control  the  convulsions.  A  high  rectal  enema  of 
the  temperature  of  110°  F.  (43.3°  C.)  is  at  once  administered.  I 
have  in  some  cases  continued  the  administration  of  chloroform  for 
fully  an  hour.  Caution  should  be  exercised  in  its  administration. 
If,  after  the  seizure,  the  temperature  is  high,  it  is  treated  as  indi- 
cated in  the  section  on  Infectious  Diseases.  Unless  there  is  some 
contraindication,  a  full  dose  of  calomel  is  administered  as  a  routine 

51 


802  DISEASES  OF  TEE  NERVOUS  SYSTEM. 

procedure  even  if  an  enema  has  been  resorted  to.  Should  the  child 
be  restless,  it  is  well  after  the  convulsion  to  administer  a  dose  of 
bromide  of  potassium  in  combination  with  chloral,  either  by  mouth 
or  rectum.  In  repeated  convulsions  the  administration  of  these 
drugs  during  the  seizures  is  of  inestimable  value. 

For  several  years  past  I  have  used  the  postural  treatment  in  acute 
convulsive  seizures.  The  patient  is  placed  with  the  head  low,  the 
buttocks  raised,  and  the  clothes  loosened.  I  think  the  paroxysms 
have  been  shortened  by  this  treatment.  It  was  suggested  by  the 
theory  that  cerebral  anaemia  is  the  cause  of  the  initial  paroxysm.  I 
have  carried  out  this  postural  treatment  without  any  ill  after  effects, 
such  as  hemorrhage.  In  a  large  number  of  cases  of  repeated  con- 
vulsions, the  postural  treatment  should  be  supplemented  by  chloro- 
form inhalations. 

HYSTERIA. 

Hysteria  is  a  morbid  state  of  the  nervous  system  in  which  the 
primary  derangement  is  in  the  higher  cerebral  centres.  The  lower 
centres  of  the  brain,  the  spinal  cord,  and  the  sympathetic  system  may 
be  secondarily  disordered  (Gowers).  It  is  not  a  true  disorder  of 
childhood.  Sixteen  per  cent,  of  all  the  cases  of  hysteria  occur  in 
youth  (Steiner). 

Etiology. — Hysteria  is  rarer  in  children  than  in  adults,  is  more 
frequent  in  the  female  sex,  and  is  more  often  seen  in  boys  than  in 
men.  According  to  Briquet  and  Landouzy,  8  per  cent,  of  all  the 
cases  occur  in  the  first  decade  of  life,  and  50  per  cent,  in  the  second. 
The  cases  of  the  first  decade,  according  to  Barlow,  generally  develoj^ 
at  the  age  of  six  years.  Cases  are  occasionally  seen  in  patients  of 
the  age  of  three  years.  Heredity  plays  an  important  etiological  role. 
Moral  and  mental  influences  predispose  to  development  of  the  con- 
dition. Children  of  emotional  antecedents  are  apt  to  be  subject  to 
the  disease.  Sexual  disturbances  or  excesses  (as  masturbation  in 
boys),  are  exciting  causes.  Abnormalities  of  the  sexual  organs,  phi- 
mosis, and  hypospadias  are  apt  to  excite  masturbation  and  resultant 
hysteria.  In  some  subjects,  any  acute  disease,  such  as  pneumonia  or 
typhoid  fever,  will  develop  latent  tendencies  to  hysteria.  Diph- 
theritic paralysis  may  eventuate  in  hysterical  palsy  (Gowers). 

Symptoms. — The  disease  shows  many  variations  and  most  diverse 
symptoms.  The  symptoms  may  be  divided  into  psychic,  motor,  and 
sensory  manifestations;  or  into  the  convulsive  and  non-convulsive 
forms  of  hysteria. 

Psychic  or  Menial  Hysteria  (Non-convulsive). — In  most  cases 
of  this  class,  the  patients  suffer  from  some  mental  strain.  The 
attack  begins  with  a  paroxysm  of  crying  or  of  laughing.     The  child 


HYSTEBIA.  803 

then  passes  into  a  violent  condition,  striking  at  persons  and  tearing 
the  clothes  from  its  body.  I  saw  a  case  of  this  kind  in  a  boy  eight 
years  of  age.  He  was  very  bright  at  school,  but  shunned  the  com- 
panionship of  other  boys.  He  masturbated.  At  times  he  was  of  a 
very  loving  disposition,  at  other  times  would  refuse  to  do  as  he  was 
told.  The  rebellion  would  terminate  in  a  paroxysm  of  crying,  fol- 
lowed by  one  of  shrieking.  The  boy  would  tear  his  clothes  and  then 
calm  down  quite  exhausted.  Girls  after  undergoing  some  mental 
strain,  such  as  is  incident  to  a  school  examination,  become  irritable, 
morose,  and  suffer  from  insomnia.  They  have  laughing  and  crying 
spells  and  refuse  nourishment.  After  a  period  of  these  symptoms 
they  either  recover  or  pass  into  a  state  resembling  acute  mania. 
Such  children  are  nervous  and  are  born  of  neurotic  parents. 

Hystero-epilepsy,  catalepsy,  or  trance  symptoms  may  manifest 
themselves.  These  cases  are  rare  in  children,  but  Sachs  and  Steiner 
have  seen  them  in  children  of  mentally  degenerate  families. 

Insanity,  alcoholism,  and  chorea  in  the  family  predispose  to  the 
development  of  hysteria.  These  cases  must  be  differentiated  from 
those  of  true  epilepsy. 

Motor  Manifestations  (Convulsive  Forms). — These  occur  in  the 
form  of  hystero-epileptic  attacks.  After  some  mental  excitement  a 
paroxysm  beginning  with  a  shriek  will  supervene,  the  sounds  simu- 
lating a  bark  or  a  snapping  sound.  Contortions  then  supervene  and 
the  back  is  arched,  as  shown  in  Richer's  drawings.  During  the 
attack,  which  may  last  for  several  minutes,  there  may  be  no  evidence 
of  consciousness.  There  may  be  a  number  of  such  attacks  in  the 
course  of  twenty-four  hours.  The  patient  may  suddenly  fall  down 
and  have  contortions,  and  the  attack  may  terminate  in  a  crying  spell. 
The  patients  sometimes  tear  their  clothing  and  become  violent. 
These  convulsions  are  differentiated  from  true  epilepsy  in  that  there 
is  no  aura ;  they  are  preceded  by  emotional  excitement.  The  onset 
is  gradual  and  the  patients  emit  noises  of  various  kinds  during  the 
attack.  The  pupils  are  normal.  There  are  ecstasy,  extravagant 
movements,  and  tonic  rigidity.  The  vesical  and  rectal  reflexes  are 
normal.  The  patients  do  not  bite  the  tongue,  and  rarely  injure 
themselves;  the  loss  of  consciousness  is  temporary  or  imperfect. 
There  are  in  hysteria  irregular  twitchings  of  the  extremities  and  a 
repetition  of  one  specific  movement,  such  as  retraction  of  the  head. 
The  spell  or  paroxysm  ends  in  a  crying  or  laughing  fit,  or  the  patients 
become  melancholic. 

Among  the  manifestations  of  hysteria  in  children  is  the  so-called 
hysterical  stricture  of  the  oesophagus,  or  globus  hystericus.  There 
may  be  spasm  of  the  bladder,  hiccough,  and  loss  of  voice.  The  latter 
is  common  among  young  girls.     I  have  seen  the  children  recover 


804  DISEASES  OF  TEE  NEEFOUS  SYSTEM. 

their  voice  under  hyj^notic  suggestion.  Hysterical  children  may, 
even  at  the  early  age  of  five  years,  pass  under  hypnotic  suggestion, 
into  a  trance-like  state.  Whether  diarrhoea  can  he  caused  hy  hysteria 
is  in  my  opinion  doubtful.  I  have  seen  true  toxic  diarrhoea  in  neu- 
•  rotic  children  diag-nosed  as  nervous  or  hysterical.  One  case  occurred 
in  a  boy  of  six  years.  Some  young  girls  have  attacks  in  which  all 
varieties  of  poses  are  assumed  in  the  nude  state.  I  have  seen  such 
a  case  in  a  highly  intelligent  girl  of  nine  years.  During  the  morn- 
ing bath  the  child  had  a  desire  to  assume  the  most  grotesque  poses. 

The  so-called  epidemics  of  chorea  are  now  known  to  be  simple 
hysteria.  Among  these  are  to  be  classed  the  school  epidemics  and 
the  dancing  mania  of  the  Middle  Ages. 

There  may  not  only  be  convulsive  movements,  but  also  absolute 
paralysis  of  single  muscles  or  of  a  group  of  muscles.  Hysterical 
paralyses  as  a  rule  follow  no  anatomical  distribution.  They  are  dis- 
tinguished from  true  palsies  by  the  lack  of  change  in  the  electrical 
reactions  and  in  the  condition  of  the  deep  reflexes.  The  sphincters 
are  normal.  Paralyses,  such  as  those  due  to  neuritis  or  poliomye- 
litis, may  supervene  in  a  hysterical  subject. 

Disturbances  of  Sensation. — The  disturbances  of  sensation  in- 
clude hyj)era?sthesias  and  anaesthesias.  These  do  not  differ  essen- 
tially from  similar  conditions  in  the  adult  subject.  There  may  be 
hypersesthesia  in  the  region  of  the  ovary,  or  in  the  skin  over  the 
vertebral  column.  Areas  of  irritation  may  cause  paroxysms.  There 
are  hysterogenic  zones  which  are  not  hypersesthetic  (Sachs).  Anaes- 
thesia, 23artial  or  general,  is  more  frequent.  There  may  be  absolute 
anaesthesia  to  all  sensation.  There  may  be  blindness  in  one  eye  or 
hemianopsia,  deafness,  or  loss  of  taste  or  of  smell.  Vision  may  be 
affected  as  above  described,  or  there  may  be  photophobia  and  diminu- 
tion of  visual  perception ;  the  retina  may  be  insensible  to  light,  and 
there  may  be  limitation  of  the  field  of  vision  or  temporary  bilateral 
loss  of  sight. 

There  are  in  children  cases  of  anorexia  which  supervene  with 
vomiting  after  some  nervous  strain.  I  have  seen  this  occur  in  chil- 
dren who  were  beginning  some  course  of  study.  In  one  case  it  came 
on  in  the  morning  just  before  the  child  started  for  school.  With 
suspension  of  school  duties,  the  vomiting  ceased.  The  so-called 
2:)hantom  abdominal  tumor  seen  in  rare  instances  among  children 
may  be  traced  to  a  hysterical  cause.  In  very  young  girls  I  have  fre- 
quently seen  forms  of  palpitation  with  cardiac  anguish  Avhich  seemed 
to  be  hysterical.  Steiner  describes  these  forms  of  tachycardia.  In 
these  cases  there  is  not  only  absence  of  cardiac  lesion  and  signs  of 
Basedow's  disease,  Idit  spinal  hyporsesthesia  may  be  elicited. 


BAD  HABITS.  805 

Diagnosis, — Sensitiveness  to  pressure  over  the  vertebral  column 
is  one  of  the  most  frequent  stigmata  of  infantile  hysteria  (Steiner). 
Epigastric  tenderness  is  less  frequent  than  among  adults.  Hyper- 
sesthesia  is  less  marked  in  childhood,  than  later  in  life,  but  is  more 
common  than  ansesthesia.  Jolly  says  that  deep  analgesia  is  rare. 
Of  especial  interest  in  its  relation  to  diagnosis  is  the  fact  that  ocular 
symptoms,  such  as  diplopia,  may  be  present  morning  and  evening. 
Paralysis  may  appear  and  disappear.  There  are  forms  in  which 
there  may  be  tachycardia  or  bradycardia,  but  during  excitement  the 
rhythm  of  the  heart  may  be  normal.  Cases  have  been  described  in 
which  the  headaches,  ptosis,  and  facial  palsies  simulate  the  symptoms 
of  tuberculous  meningitis.  Study  alone  will  clear  up  such  obscure 
cases. 

Duration  and  Course. — The  symptoms  of  hysteria  are  not  neces- 
sarily permanent,  but  are  likely  to  recur  after  excitement  or  nervous 
strain  of  any  kind. 

Treatment. — The  treatment  of  hysteria  in  children  is  based  on  the 
same  general  principles  as  in  the  adult.  The  child  is,  if  possible, 
removed  from  exciting  surroundings.  Studies  are  regulated  and 
bad  habits,  such  as  masturbation,  are,  if  possible,  corrected.  The 
effect  of  good  food  and  outdoor  life  is  marked.  Hydrotherapy  and 
m.assage  achieve  their  greatest  triumph  in  this  affection. 

BAD  HABITS. 

By  the  term  bad  habits  are  meant  a  number  of  so-called  "tricks" 
in  which  neurotic  children  are  apt  to  indulge.  They  are  not  neces- 
sarily an  indication  of  any  serious  nervous  functional  derangement. 
It  is  difficult  to  say  from  a  purely  clinical  standpoint  whether  such 
bad  habits  lead  to  any  serious  results.  They  are  in  most  cases  easily 
controlled  either  by  close  attention  to  the  cause  or  by  a  complete 
change  in  the  surroundings  of  the  patients. 

Pica  or  Dirt-eating. — Thomson  has  interested  himself  in  the 
study  of  this  peculiar  condition  in  children.  It  is  an  exaggeration 
of  the  normal  habit  seen  in  young  infants  who  invariably  place-  every- 
thing within  reach  in  their  mouths.  As  the  infant  develops,  its 
sense  of  good  and  bad  taste  teaches  that  certain  substances  are  un- 
wholesome, others  not.  In  children  who  suffer  from  pica  or  dirt- 
eating  this  sense  of  what  is  wholesome  is  lacking.  There  is  an  unex- 
plainable  yearning  after  queer  articles  of  diet,  such  as  sand,  dirt, 
gravel,  cinders,  plaster  from  walls,  or  paper.  Some  of  these  chil- 
dren are  normal  in  other  ways,  others  are  the  victims  of  so-called 
cachectic  conditions.  If  the  habit  has  been  indulged  in  for  any 
length  of  time  the  children  become  cachectic.     In  fact,   many   of 


806  DISEASES  OF  THE  NEFa'OUS  SYSTEM. 

these  children  become  the  victims  of  intestinal  parasites  (hook-worm) 
and  others  develop  a  chronic  inflammatory  state  of  the  stomach  or 
intestine.  J.  Lewis  Smith  published  a  case  in  which  a  hair-ball 
was  found  in  the  stomach  of  such  a  dirt-eating  child. 

Treatment. — The  treatment  is  one  of  vigilance  on  part  of  the 
nurse  or  guardian  in  preventing  the  indulgence  of  this  abnormal 
appetite.  A  change  of  scene  sometimes  causes  the  patient  to  forget 
his  habit.  If  cachexia  exists,  the  faeces  should  be  examined  for  the 
ova  of  parasites  which  may  have  infested  the  intestine  as  a  result  of 
dirt-eating. 

Puddling  in  Water  or  Biting  the  Finger-nails. — These  are  among 
other  habits  of  extremely  neurotic  infants  and  children. 

Thumb  Sucking. — Much  attention  has  been  directed  to  thumb 
sucking  by  recent  writers.  Lindner,  who  has  analyzed  these  cases, 
divides  them  into  two  classes,  those  of  pure  thumb  sucking  and  those 
in  which  there  is  combined  with  this  another  habit,  "  combination 
cases."  In  the  latter  the  other  hand  is  brought  into  use  while  the 
thumb  is  in  requisition,  either  to  hide  it  or  to  perform  some  other 
act,  such  as  nose-boring  or  rubbing  of  the  genitals. 

The  simplest  form  of  thumb  sucking  is  seen  in  young  infants, 
generally  in  atrophic  infants.  I  have  seen  it  in  an  atrophic  infant 
of  six  weeks.  In  such  cases  the  act  can  scarcely  be  classed  in  the 
same  category  as  when  seen  in  older  children.  In  the  former  case 
it  is  the  result  at  first  of  an  instinctive  need  of  the  infant,  probably 
a  result  of  starvation. 

In  older  children  it  may  be  looked  upon  as  an  act  of  mental  weak- 
ness; in  fact,  in  boys  and  girls  who  practice  these  acts  there  is  a 
tendency  to  mental  obtuseness.  The  act  seems  to  be  accompanied 
by  very  little  intent  in  most  children,  for  when  the  attention  is  fas- 
tened on  some  other  object  the  habit  is  quickly  forgotten.  In  other 
children  there  is  a  distinctly  surreptitious  practice  of  the  habits  of 
combination  thumb  sucking  and  nose-boring  or  genital  interference. 
The  outlook  in  most  cases  is  good  and  no  ill  effects  result.  In  cases 
where  the  children  are  mentally  backward  the  habit  is  but  a  symp- 
tom of  general  degeneracy. 

The  inculcation  of  correct  bearing  and  cleanliness  by  the  nurse 
are  in  normal  children  enough  to  put  a  stop  to  the  habit. 

Where  the  habit  is  the  result  of  mental  imbecility  nothing  can 
be  done  to  break  the  habit  except  in  a  general  educational  way  as  a 
part  of  the  treatment  of  the  mental  defect. 

Head-hanging,  Swajdng,  Head-nodding,  and  Rolling  the  Head 
from  Side  to  Side. — These  have  all  been  observed  in  mental  defectives 
of  various  grades.  The  patients  are  young  children.  The  habit 
offiirs  during  waking  and  in  most  cases,  if  the  children  are  defective 


BAB  HABITS.  807 

normally,  seems  to  be  practiced  in  an  automatic  manner  without  pur- 
pose. In  children  who  are  otherwise  normal  the  habit  is  not  difficult 
to  break.  Some  of  the  minor  habits,  such  as  bodj-swaying,  head- 
hanging  are  sometimes  seen  in  children  who  are  subject  to  violent 
outbursts  of  temper.  Such  children,  as  one  of  my  own  cases,  are 
not  only  mentally  defective  but  moral  perverts. 

Masturbation. — Masturbation  has  received  great  attention  in  this 
country  since  first  brought  to  the  notice  of  the  profession  by  Jacobi. 
Much  is  described  as  masturbation  which  is  only  a  simulation  of  the 
habit  as  seen  in  older  children  above  or  near  the  age  of  ten  years. 

Infants  and  very  young  children  are  sometimes  affected  with  the 
habit  of  so-called  thigh  rubbing  or  buttocks  rubbing.  In  them  the 
sexual  instinct  can  hardly  be  said  to  exist,  though  many  of  these 
infants  present  symptoms  in  the  act  of  thigh  rubbing  which  closely 
simulate  an  orgasm.  It  is  probably  far  from  such.  Rachford  has 
recently  fully  studied  thigh  rubbing.  He  calls  it  "  pseudo-mastur- 
bation." Most  cases  are  seen  in  young  infants ;  the  infant  will  rub 
the  thighs  together  for  a  time  and  this  will  be  accompanied,  not  by 
manifestations  of  pleasure,  but  rather  of  great  nervous  perturbation. 
The  series  of  acts  terminates  in  an  apparent  nervous  exhaustion  and 
the  mothers  will  say  the  child  seems  as  if  limp  and  may  fall  asleep 
after  the  act.  Most  of  the  patients  are  female  infants  below  the  age 
of  eighteen  months,  some  as  young  as  six  months. 

Another  form  of  pseudo-masturbation  is  seen  in  infants  who  as 
soon  as  they  are  laid  prone  on  their  backs  will  start  to  rub  the  but- 
tocks vigorously  on  the  couch.  The  motion  is  a  side-to-side  one  and 
in  this  form  of  rubbing  the  infant  may  laugh  and  evince  no  nervous 
strain.  In  both  forms  of  this  affection  there  is  found  on  close  exam- 
ination some  irritation  at  the  introitus  vaginae,  or  on  the  buttocks, 
or  between  the  thighs  to  keep  up  this  genital  irritation.  Rachford 
places  great  stress  upon  acidity  of  the  urine  as  a  causative  factor 
in  this  irritation.  I  think  most  of  these  children  are  the  victims  of 
some  oversight  in  the  nursing,  or  of  lack  of  cleanliness ;  in  male  in- 
fants the  prepuce  is  not  scrupulously  cleansed  daily.  I  do  not  think 
these  cases  ever  lead  to  any  serious  after  effects,  such  as  epilepsy,  nor 
do  I  believe  that  adhesions  either  of  the  clitoris  or  prepuce  are  causa- 
tive in  these  cases. 

The  operative  treatment,  either  in  loosening  adhesions  or  freeing 
the  clitoris,  seems  to  me  unwarranted,  as  in  my  hands  close  attention 
to  the  remedying  of  local  conditions  of  irritation  have  effected  cures 
without  the  use  of  any  special  apparatus. 

Masturbation,  as  it  is  seen  in  older  children,  is  an  entirely  dif- 
ferent affection  from  that  just  described.  Here  the  sexual  instinct 
has  either  prematurely  developed  or  above  ten  years  of  age  it  is 


808  DISEASES  OF  IRE  XEEVOUS  SYSTEM. 

actually  present.  We  then  have  true  masturbation.  Masturbation 
is  an  exceedingly  prevalent  habit  among  children  of  all  classes. 
There  is  a  tendency  to  interfere  with  the  genitals  common  to  both 
sexes.  Only  the  flagrant  cases  come  under  the  notice  of  the  physi- 
cian. The  children  may  be  bright,  others  are  not  so  bright,  but  all 
are  highly  neurotic  and  come  of  neurotic  stock. 

Most  serious  are  the  cases  in  which  the  habit  is  practiced  in 
secret.  Here  we  have  evident  interference  with  the  mental  peace 
of  the  patient.  Other  cases  are  seen  in  children  who  are  quite  inno- 
cent of  any  immoral  intent.  Such  was  a  case  of  mine  in  which  a 
child  with  high  moral  standards  contracted  the  habit  from  irri- 
tation of  the  vulva  as  a  result  of  horseback  riding.  A  cessation  of 
the  horseback  riding  and  local  treatment  with  moral  suasion  was 
enough  to  cure  the  habit.  In  boys  the  problem  of  curing  becomes 
very  difficult.  The  only  way  seems  to  me  to  be  educational  explana- 
tion and  a  stimulation  of  the  mind  to  moral  cleanliness.  Any  use  of 
mechanical  apparatus  is  certainly  degrading  to  sensitive  children  and 
leads  to  no  good  results.  In  those  cases  in  which  the  habit  is  the 
result  of  a  general  mental  defectiveness  the  treatment  and  manage- 
ment of  the  masturbation  becomes  one  of  the  features  of  the  general 
management  of  these  cases. 

TETANY. 
{Tetanilla;  Arthrogryposis.) 

Tetany  is  an  intermittent  or  persistent,  more  or  less  painful 
tonic  spasm  of  groups  of  muscles  of  the  upper  and  lower  extremities. 

Forms  and  Frequency. — Haviland  in  1813  and  Clark  in  1815  de- 
scribed this  disease  in  children.  Trousseau,  Baginsky,  Chvostek. 
Erb,  and  Escherich  have  completed  its  symptomatology.  It  is  most 
frequent  from  the  third  month  to  the  end  of  the  second  year  of  life. 
Griffith  found  that  68  per  cent,  of  the  cases  occurred  before  the 
second  year  of  childhood.  The  greatest  number  of  cases  occur  in 
the  eighth  month  of  infancy  (Escherich).  As  to  age,  the  forms  are 
the  infantile,  the  tetany  of  early  and  late  childhood  and  adult  tetany. 
including  the  surgical  variety.  As  to  duration,  we  have  the  forms 
in  which  the  contractures  are  intermittent,  coming  on  at  intervals, 
the  patients  being  free  from  muscular  spasm  in  the  intervals.  The 
second  form,  now  accepted  by  the  majority  of  writers  as  the  same 
affection  as  the  former,  is  that  in  which  the  contractures  are  persistent. 

Etiology. — The  etiology  of  this  affection  is  still  very  obscure.  It 
occurs  most  frequently  in  the  winter  and  early  spring.  In  my  expe- 
rience in  an  ambulatory  clinic,  it  was  customary  to  see  these  cases 
appear  in  groups  in  the  early  spring  months.     The  affection  is  seen 


TETANY.  809 

under  the  most  diverse  conditions.  Fully  63  per  cent,  of  the  cases 
are  rachitic  (Fischl).  The  percentage  of  rachitis  must,  of  course, 
vary  in  different  countries,  but  the  cases  coming  under  my  notice 
have  been  chiefly  of  that  character.  The  condition  is  not,  as  is  fre- 
quently supposed,  a  rare  one.  I  have  regularly  seen  a  number  of 
these  cases  yearly.  Many  cases  of  tetany  are  not  recogTiized  as  such 
by  the  physician.  Cold,  entozoa,  infections  of  the  gut,  chronic 
intestinal  disturbances  of  all  kinds,  rachitis,  an  enlarged  thymus 
(Escherich),  have  all  in  turn  been  regarded  as  etiological  factors. 
On  the  other  hand,  some  attribute  the  affection  to  a  toxaemia  prob- 
ably originating  in  the  gut  and  expending  itself  on  the  peripheral 
motor  nerves.  Fully  73  per  cent,  of  Fischl's  cases  had  shov^^n  intes- 
tinal disturbances.  The  fact  that  the  condition  occurs  in  early 
infancy  and  in  some  respects  resembles  a  normal  state,  to  be  de- 
scribed later,  v^ill  account  for  its  being  frequently  overlooked  by  the 
physician. 

The  symptoms  of  tetany  are  traced  by  Stoltzner  and  Cybulski 
to  a  deficiency  of  retained  calcium  salts  in  the  body.  Under  a  covr's 
milk  diet  only  half  of  the  calcium  is  retained  as  compared  to  a 
breast-milk  diet.  This  is  not  generally  accepted.  Escherich  and 
Erdheim  recently  proved  that  in  tetany  there  is  a  species  of  para- 
thyroid priva,  a  deficiency  in  the  function  of  these  glands.  He  has 
found  lesions  in  the  parathyroids  of  infants  dying  of  tetany.  Such 
lesions  may  interfere  with  the  function  of  the  parathyroid  under 
exciting  causes  of  malnutrition  or  infectious  diseases.  With  this 
there  is  an  unequal  distribution  of  calcium  salts  in  the  body  (Leo- 
pold), and  from  this  tetany  may  result. 

Morbid  Anatomy.— ISTo  definite  account  of  the  changes  in  the 
nervous  system  or  elsewhere  has  as  yet  been  given.  Langhans  has 
described  a  peri-arteritis  and  phlebitis  in  the  white  commissure  and 
cervical  portion  of  the  cord.  Gowers,  without  any  positive  data, 
assumes  that  there  are  some  changes  in  the  motor  cells  of  the  cord 
which  cause  the  increased  irritability  of  the  peripheral  motor  nerves. 
Fischl  in  a  recent  article  has  published  the  postmortem  changes  in 
his  fatal  cases.  He  makes,  however,  no  comment  on  them.  He 
found  hydrocephalus  interna  and  externa,  oedema  of  the  brain  and 
meninges,  tuberculosis  of  the  brain,  hemorrhagic  infiltration  of  the 
cerebellum  and  meninges,  chronic  intestinal  catarrh,  and  broncho- 
pneumonia.    The  affection  occurs  under  the  most  diverse  conditions. 

The  investigations  of  Erdheim  on  rats  and  of  Escherich  in  the 
human  have  revealed  hemorrhages  and  epithelial  lesions  in  the  para- 
thyroid bodies  or  epithelial  bodies.  In  one  of  my  cases  of  tetany 
such  hemorrhages  were  substantiated. 


810 


DISEASES  OF  THE  NEEVOUS  SYSTEM. 


Symptoms. — The  symptoms  consist  of  muscular  contractures  and 
phenomena  connected  with  the  peripheral  motor  nerves,  which  are 
known  as  Trousseau's  phenomenon,  Chvostek's  facial  symptom,  and 
Erb's  signs  of  increased  electrical  excitability  of  nerve  and  muscle. 

Muscular  Contractures. — These  come  on  without  any  premoni- 
tory symptoms.  The  infant  or  child  may  have  been  in  good  health, 
or  may  have  been  suffering  from  intestinal  disturbance.  There  are 
two  distinct  forms  of  contracture  in  infants,  in  one  of  which  the 


Fig.  182. 


Tetany. 


Extension   of  the   fingers,   flexion   of  the   arms,   flexion  of  the  toes.     Facies. 
Child,  eighteen  months   of  age. 


hands  and  arms  take  the  position  assumed  in  driving  horses  (Plate 
XXXVI.).  The  arms  are  pressed  against  the  thorax,  the  forearms 
flexed  on  the  arms,  and  the  fingers  tightly  flexed  over  the  thumb  into 
the  palm  of  the  hand.  The  hand  itself  is  strongly  flexed  on  the 
forearm.  The  lower  extremities  may  be  adducted  toward  the  me- 
dian line,  the  thighs  flexed  on  the  abdomen,  and  the  legs  on  the 
thighs.  .The  feet  are  as  a  rule  extended  in  the  equinus  position  and 
the  toes  overflexed  on  the  plantar  aspect  of  the  foot,  the  whole  foot 


PLATE   XXXVl 


Tetany.  Infant  iiine  months  of  age.  Shows  the  driving 
position  of  the  fingers,  hands,  and  arms,  overextension  of 
the  feet  and  flexion  of  the  toes. 


TETANY.  811 

being  slightly  curved  inward.  After  the  contractures  have  lasted 
some  time,  there  is  oedema  of  the  tissues  over  the  dorsum  of  the  foot. 
In  the  second  set  of  cases  the  fingers  are  overextended,  as  shov^^n  in 
Fig.  182.  The  arms  and  lower  extremities  also  take  the  position 
of  flexion.  These  contractures  are  painful ;  the  patient  cries  as  if 
in  great  pain  when  an  attempt  is  made  to  straighten  the  fingers  or 
extremities.  There  may  be  a  temperature  of  two  or  three  degrees. 
The  contractures  may  diminish,  and  there  may  be  an  interval  in  which 
the  only  symptoms  are  such  as  may  be  attributed  to  the  increased 
mechanical  and  electrical  irritability  of  the  peripheral  nerves.  There 
may  also  be  eclampsia.  The  eclamptic  attacks  are  very  dangerous. 
I  have  lost  2  cases  in  such  seizures.  Other  muscles,  such  as  the" 
abdominal  or  thoracic,  may  be  the  seat  of  contracture.  In  the  latter 
case  there  may  be  cyanosis. 

I  have  seen  cases  in  which  all  the  muscles  of  the  body  were 
involved  very-much  as  in  tetanic  conditions.  In  one  case  there  were 
stiffness  of  the  muscles  of  the  neck  and  loss  of  consciousness.  Tris- 
mus is  rare,  and  certainly  does  not  occur  at  the  outset,  as  in  tetanus. 
The  muscles  of  the  face  may  be  subject  to  contracture.  The  brow 
is  wrinkled,  and  the  face  has  an  anxious  expression.  If  the  muscles 
over  the  zygoma  are  tapped,  thei*e  is  an  instantaneous  contracture 
or  spasm  of  the  orbicularis  palpebrarum.  In  some  cases,  if  the 
muscles  of  the  face  or  the  forehead  are  tapped,  there  is  an  instanta- 
neous contracture  of  the  muscles  of  the  face,  and  sometimes  of  other 
muscles  of  the  body.  This  is  called  the  facial  phenomenon  of 
Chvostek.  If  the  nerves  and  arteries  at  the  bend  of  the  elbow  are 
compressed,  the  characteristic  tetany  position  is  produced  in  the 
muscles  of  the  hand  and  fingers.  This  phenomenon  was  first  noticed 
by  Trousseau,  and  bears  his  name.  Erb  established  the  fact  that 
there  is  increased  irritability  of  nerve  and  muscle  to  the  faradic  and 
galvanic  current.  If  the  muscles  or  nerves  elsewhere  in  the  body 
are  tapped,  or  if  pressure  is  brought  to  bear  at  the  point  of  exit  of 
the  nerve-trunks,  there  is  an  excessive  irritability  to  this  mechanical 
stimulus.     The  knee  reflex  is  increased. 

Escherich  and  V.  Pirquet  have  recently  shown  that  there  is  in 
tetany  an  increased  electrical  excitability  of  nerve  to  low  stimuli. 
With  a  current  of  four  milli amperes  there  is  muscular  contraction  on 
kathodal  opening  and  closure  as  well  as  anodal  opening  and  closure. 

Duration. — The  disease  may  last  a  few  hours,  days,  or  weeks.  In 
many  cases  the  contractures  disappear  for  a  time,  leaving  the  patient 
perfectly  free  from  symptoms.  They  may  return  in  all  their  orig- 
inal severity.  The  attacks  leave  the  peripheral  nerves  in  a  condition 
of  increased  excitability.  In  such  cases  both  the  Chvostek  and 
Trousseau  phenomena  may  be  present. 


812  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Diagnosis. — The  diagnosis  of  fully  developed  tetany  is  based  on 
the  presence  of  mnseular  contractures,  of  increased  electrical  and 
mechanical  irritability  of  the  peripheral  nerves  (as  evinced  in  Chvo- 
stek's  symptom)  and  the  presence  of  Trousseau's  phenomenon.  There 
are  cases  of  tetany  in  which  the  facial  symptoms  are  lacking.  On 
the  other  hand,  I  have,  in  cases  in  which  there  was  laryngospasm  with- 
out contractures,  obtained  both  the  facial  and  Trousseau  phenomena. 

The  Relationship  of  Laryngospasm  to  Tetany. — Escherich,  his 
pupil  Loos,  and  also  Ganghofner,  have  recently  called  attention  to 
the  fact  that  laryngospasm  is  present  in  a  certain  number  of  cases 
of  tetany.  They  also  found  that  cases  of  laryngospasm  which  did 
not  present  contractures,  did  show  the  facial  phenomenon  of  Chvostek 
and  the  Trousseau  symptom.  They  concluded  that  laryngospasm 
was  a  manifestation  of  tetany,  whether  the  muscle  contractures  were 
present  in  the  extremities  or  not.  Their  observations  have  been 
amply  confirmed,  but  not  all  observers  are  as  yet  willing  to  accept 
laryngospasm  without  contractures  of  the  muscles  of  the  extremities 
as  true  tetany.  The  views  of  Kassowitz  and  Hochsinger  are  at 
variance  with  those  of  Escherich.  They  consider  rachitis  the  fun- 
damental cause  of  laryngospasm,  if  not  of  tetany. 

Latent  Tetany.- — -The  term  latent  tetany  has  been  applied  to  those 
cases  which  show  no  muscular  contractures  or  laryngospasm,  but  in 
which  the  facial  Trousseau  or  Erb  phenomenon  may  be  elicited,  or 
in  which  the  mechanical,  and  especially  the  electrical,  contractibility 
of  muscle  and  nerve  are  increased. 

Accidental  Symptomatic  Form  of  Infantile  Tetany.- — There  are 
forms  of  tetany  which  occur  in  a  symptomatic  way  in  combination 
with  other  diseases;  such  are  called  the  accidental  tetanies.  They 
occur  mostly  beyond  the  third  year  of  life  and  in  children  who  as 
a  rule  have  suffered  from  convulsions  and  laryngismus,  and  in  whom 
the  symptoms  of  tetany  reappear  in  concurrence  with  some  acute 
disease,  such  as  pneumonia. 

In  these  children  we  have  the  facial  phenomenon,  typical  elec- 
trical reactions,  and  the  tetanic  contractions  of  the  hands  and  lower 
extremities.  Such  a  recurrence  has  been  observed  by  Finckelstein 
in  grippe,  influenza,  whooping  cough,  acute  gastro-enteritis,  etc. 
These  cases  have  been  more  or  less  confused  with  those  of  meningitis. 

Persistent  Form  of  Infantile  Tetany. — This  is  characterized  by  its 
long  duration.  The  muscular  contraction  is  not  so  marked  and 
tetanic  as  in  the  acute  cases,  but  manifests  itself  rather  in  in- 
creased contractions  of  all  the  muscles  of  the  affected  part  of  the  body, 
a  hypotonia  of  the  muscles,  and  difficulty  and  slowing  of  the  volun- 
tary motion.  The  muscles  are  hard,  contracted  and  in  severe  cases 
rather  prominent.     The  contractures  are  mostly  bilateral  and  affect 


TETANY.  813 

by  preference  the  distal  end  of  the  extremities.  Thus  we  have 
manifested  the  "  accoucheur  "  position  of  the  hands,  supination  and 
flexion  of  the  feet  which  occurs  in  the  typical  tetany  conditions. 

In  some  cases  there  is  the  picture  of  simple  hypotonia  existing 
during  rest  or  sleep.  The  active  muscular  motion  is  slow  and  per- 
formed with  difficulty,  as  if  overcoming  some  resistance.  In  some 
a  high  degree  of  muscular  tension  is  ^^resent,  voluntary  motion  is 
entirely  impossible  and  we  have  the  picture  of  a  spastic  contracture 
which  affects  the  muscles  of  the  trunk  and  face,  causing  neck  rigidity 
and  opisthotonos.  These  cases  may  very  closely  resemble  the  so- 
called  "  womb "  tetany  and  they  have  been  called  pseudo-tetanies. 
Especially  interesting  are  cases  in  which  there  is  only  contraction 
of  muscles  of  one  side  of  the  body,  or  contraction  of  a  particular 
group  of  muscles. 

There  have  been  no  postmortems  in  these  cases,  and  the  question 
as  to  whether  these  cases  are  those  of  true  tetany  is  still  in  doubt. 

Escherich  insists  that  inasmuch  as  the  pathognomonic  electrical 
reactions  are  present  in  these  cases,  they  should  be  classed  as  tetany. 

In  addition  we  have  the  Erb,  Chvostek,  and  the  Trousseau  phe- 
nomenon, extending  over  a  long  period  of  time. 

Late  Tetany:  Tetany  of  Later  Childhood:  Puerile  Tetany. — By 
puerile  tetany  we  mean  that  occurring  after  the  third  year  of  life. 
These  cases  are  distinctly  separated  from  those  of  infantile  tetany, 
and  in  them  the  main  symptoms  of  the  clinical  picture  of  infantile 
tetany,  such  as  laryngospasm  and  convulsive  attacks,  are  relegated 
to  the  background.  On  the  other  hand,  muscular  spasm,  especially 
the  typical  carpo-pedal  spasm  accompanied  by  pain  and  hyperes- 
thesia, is  quite  marked.  On  this  account,  the  shorter  duration  and 
the  better  prognosis  of  the  disease  is  explained.  In  this  respect 
puerile  tetany  resembles  very  closely  the  tetany  of  adults. 

Prognosis  and  Mortality. — The  prognosis  in  the  sporadic  cases  is 
very  good.  The  gravest  cases  are  those,  in  which  convulsions  and 
laryngospasm  are  combined  with  symptoms  of  tetany.  Parents 
should  be  cautioned  in  regard  to  the  excitability  of  the  patient  and 
the  possibility  of  eclampsia,  with  its  fatal  consequences.  I  have  lost 
4  cases  in  convulsions.  The  persistent  cases  may  be  complicated 
with  other  affections,  such  as  tuberculous  meningitis.  If  such  is  the 
case,  the  outcome  is,  as  in  the  primary  disease,  fatal.  Epidemics 
in  hospitals  for  children  present  unfavorable  features ;  Escherich  lost 
37  per  cent,  of  his  cases. 

Treatment. — The  bowels  should  first  be  evacuated.  Calomel  is 
given  in  grain  -|  (0.03)  doses  two  or  three  times  daily.  If  there  is 
any  disturbance  of  the  gut,  the  patient -is  given  a  high  enema  once  a 
day.     Milk  is  suspended  until  the  movements  take  on  a  more  favor- 


814 


DISEASES  OF  TEE  XEErOUS  SYSTEM. 


able  appearance.  The  infant  is  kept  nnder  the  influence  of  the 
mixed  bromides  of  potassium,  sodium,  and  ammonia.  If  there  is 
eclampsia  or  increased  irritability,  a  warm  bath  is  given  at  least 
once  a  day.  The  patient  is  kept  quiet  and  not  disturbed  much.  No 
attempt  to  straighten  the  limbs  should  be  made,  since  it  causes  pain. 

Fig.  183. 


Cataleptic  state  produced  in  a  child  following  typhoid  fever. 

In  view  of  the  fact  that  cases  of  surgical  tetany  are  improved  by 
calcium  lactate,  this  drug  has  been  recommended  iii  infantile  tetan}-. 
Five  grains  are  given  internally  three  times  daily.  Feeding  is  of 
first  importance  and  breast-milk  is  the  most  desirable  food. 


CATALEPSY. 

Epstein  has  described  a  condition  in  children  closely  resembling 
a  similar  affection  in  the  adult.  He  has  described  it  as  catalepsy 
occurring  in  infants  poorly  nourished  and  rachitic.  The  ages  of  his 
cases  ranged  from  eighteen  months  to  three  and  one-half  years. 
Epstein  believes  there  is  a  disturbance  of  the  psychomotor  functions. 
The  phenomenon  was  observed  by  him  chiefly  in  the  lower  extremi- 
ties. Either  extremity  on  being  lifted  into  the  air  would  stay  there 
for  a  length  of  time  in  any  position  of  flexion  or  extension  in  which 
it  was  placed.     This  phenomenon  was  not  present  during  sleep,  nor 


CONGENITAL  STBIDOE  OF  INFANTS.  815 

was  it  accompanied  bj  any  muscular  rigidity  or  increase  of  mechan- 
ical or  electrical  irritability  of  the  perijDheral  nerves.  I  have  met 
a  marked  case  of  catalepsy  follov^^ing  an  attack  of  typhoid  fever  in  a 
child  of  four  years.  The  hands,  arms,  and  lov^er  extremities  would 
remain  for  long  periods  of  time  in  the  position  in  which  they  were 
placed.  The  patient  would  sit  for  long  periods  staring  ahead,  with- 
out winking  the  eyes  (Fig.  183). 

MYOTONIA. 

Myotonia  physiologica  neonatorum  is  a  term  applied  by  Hoch- 
singer  to  the  normal  tendency  of  the  newly  born  infant  to  ilex  the 
fingers,  arms,  and  lower  extremities.  There  is  a  slight  rigidity  which 
is  a  hypertonicity  of  the  muscle,  and  which  lasts  until  the  third 
month.  The  position  closely  resembles  that  of  the  extremities  of  the 
foetus  in  utero.  The  myotonia  is  exaggerated  if  the  infant  becomes 
ill  with  any  intercurrent  affection,  such  as  syphilis.  The  condition 
cannot  be  mistaken  for  tetany  if  the  differences  between  the  normal 
and  the  abnormal  states  of  the  peripheral  nerves  are  borne  in  mind. 

CONGENITAL  STRIDOR  OF  INFANTS. 

(Thomson.) 

This  rare  condition  has  for  a  long  time  been  classified  by  writers 
as  a  mild  form  of  laryngismus  stridulus.  I  have  seen  one  case  in 
which  there  was  also  laryngismus.  The  affection  is  a  distinct  one, 
is  generally  congenital,  and  appears  soon  after  birth.  Some  years 
ago,  I  presented  a  case  of  the  kind  before  the  Pediatric  Section  of 
the  Academy  of  Medicine  of  ISTew  York.  Since  then  I  have  seen  a 
number  of  cases.  Thomson  has  fully  described  and  studied  the  affec- 
tion. Thie  infant  is  usually  in  other  respects  normal,  but  I  have 
seen  the  condition  in  infants  with  signs  of  rachitis.  The  ages  of  the 
patients  varied  from  nine  weeks  to  twelve  months.  In  one  case  there 
was  a  history  of  attacks  of  laryngismus  stridulus,  occurring  shortly 
after  birth.  In  most  of  the  cases,  the  symptoms  were  noticed  soon 
after  birth.  The  respiration  is  more  or  less  noisy,  being  sometimes 
scarcely  audible  and  at  other  times  so  loud  as  to  be  heard  at  some 
distance.  Inspiration  is  accompanied  by  a  peculiar  croaking,  grunt- 
ing noise. 

As  a  rule,  expiration  is  noiseless,  but  it  may  be  accompanied  by 
a  grunting  sound,  there  being  short  intervals  in  which  no  sound  is 
heard.  The  infants  are  not  at  all  disturbed  by  the  condition.  They 
sit  and  play,  emitting  this  peculiar  croak  while  breathing.  In  mild 
cases,  nothing  is  seen  in  the  thorax.     I  have,  however,  seen  the  draw- 


816 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Fig.  184. 


ing  inward  of  the  suprasternal  region  which  Thomson  describes.  In 
one  case  the  noise  was  louder  at  night.  If  the  stethoscope  is  held 
over  the  situation  of  the  vocal  cords,  it  will  be  ascertained  that  the 
sound  is  produced  in  the  larynx  and  not  in  the  pharynx. 

The  causation  is  obscure;  the  theory  advanced  by  Thomson  is 
that  there  is  an  ill-coordinated  spasmodic  action  of  the  muscles  of 
respiration,  choreiform  in  character  and  similar  to  that  present  in 
stammering.  This  influence,  acting  on  the  epiglottis  from  birth, 
causes  a  deformity  of  the  organ,  which  in  turn  perpetuates  the  crow- 
ing noise.  Others  have  attributed  this  condition  to  the  presence  of 
an  enlarged  thymus  (Variot).  Some  of  these  infants  are  distinctly 
lymphatic,  and  Hochsinger  has  lately  with  a;-ray  demonstrated  what 
he  believes  to  be  an  enlarged  thymus  in  many  of  the  cases  of  laryngeal 
stridor  coming  under  his  notice.     He  believes  the  condition  due  to 

an  enlarged  thymus,  and  suggests  that 
the  term  "Asthma  thymicum"  be  ap- 
plied to  these  cases.  Lee  and  Refslund 
have  published  two  cases  with  autopsy 
in  which  laryngeal  stridor  existed  from 
birth  and  in  which  there  was  an  anatom- 
ical malformation  of  the  epiglottis. 
This  consisted  in  a  folding  of  the  epi- 
glottis laterally,  so  that  the  aryepiglottic 
folds  were  almost  in  contact.  The  supe- 
rior opening  of  the  larynx  was  thus  cov- 
ered by  the  deformed  epiglottis  in  such 
a  way  that  respiration  took  place  through 
a  mere  slit  of  epiglottis,  hence  the  grunt- 
ing or  sawing  noise.  I  have  recently 
published  a  case  of  laryngeal  stridor 
dying  of  intercurrent  pneumonia  (Fig. 
184).  This  case  showed  the  same  mal- 
formation of  the  epiglottis  described  by  Lee  and  Refslund,  and  would 
support  the  theory  of  anatomical  deformity  as  a  causative  factor  in 
these  cases.  Toward  the  second  year  of  life  the  condition  gradually 
disappears  spontaneously. 


Larynx  from  author's  case  of 
laryngeal  stridor.  Patient  13 
months  of  age. 


LARYNGISMUS  STRIDULUS. 

(Spasm  of  the  Glottis.) 

Laryngismus  stridulus  is  a  spasmodic  functional  nervous  disorder 
of  the  glottis,  involving  the  muscles  of  inspiration  and  expiration. 

Occurrence. — The  affection  is  more  frequent  in  boys  than  in  girls. 
It  is  most  common  in  the  first  year  of  life.     The  majority  of  the 


LARYNGISMUS  STRIDULUS.  817 

cases  occur  before  the  end  of  the  second  year.  Kassowitz  found 
348  of  370  cases  to  occur  before  that  time.  It  may  occur  in  the 
newly  born  infant  (Henoch,  Kassowitz).  Most  of  the  infants  and 
children  affected  by  this  disorder  are  subjects  of  rachitis  and  also 
show  signs  of  craniotabes.  Henoch  estimates  the  frequency  of 
rachitis  at  75  per  cent.  Only  one  of  the  cases  of  Kassowitz  did  not 
show  its  signs.  All  but  48  showed  craniotabes.  On  the  other  hand, 
Boral  shows  that  4  per  cent,  of  all  children  with  rachitis  have  laryn- 
gismus stridulus. 

Etiology. — The  etiology  of  this  affection  is  obscure.  Although 
rachitis  is  so  frequent  an  accompaniment  of  the  disorder,  it  may  not 
yet  be  assumed  that  it  is  the  exciting  cause.  Craniotabes,  which 
is  a  part  of  the  symptom-complex,  has  been  regarded  as  the  cause 
(Elsasser). 

Escherich,  Loos,  Gee,  and  Ganghofner  have  placed  laryngismus 
stridulus  in  the  same  category  as  tetany,  and  trace  it  to  the  same 
exciting  cause.  Keflex  irritation  from  the  stomach  acting  through 
the  vagus  is  the  theory  of  Baginsky.  In  many  cases  which  have 
terminated  fatally  an  enlarged  thymus  has  been  found.  On  the 
other  hand,  there  have  been  postmortems  which  showed  a  rather 
small  thymus  and  slightly  enlarged  bronchial  nodes   (Baginsky). 

Morbid  Anatomy. — i^o  definite  study  has  been  made  of  the  changes 
found  in  the  fatal  cases.  Most  cases  show  oedema  of  the  brain  and 
some  fluid  in  the  ventricles,  rachitis  slight  or  pronounced,  the  thymus 
small  or  enlarged,  and  the  lymph-nodes  slightly  enlarged.  The  cases 
with  enlarged  thymus  thus  far  published  have  not  been  convincing. 
Children  with  enlarged  thymus  die  of  other  disorders,  and  without 
having  had  during  life  any  symptoms  of  spasm  of  the  glottis. 

Symptomatology. — The  spasm  or  paroxysm  comes  on  suddenly. 
Without  the  least  warning,  the  child  throws  the  head  back  and  stops 
breathing;  the  face  becomes  livid,  the  arms  are  flexed  and  the  hands 
clenched.'  jSTo  respiratory  movement  takes  place  for  a  few  seconds. 
There  is  then  a  long-drawn  whistling  or  crowing  inspiratory  sound. 
This  is  the  classical  form  of  spasm  of  the  larynx.  The  paroxysm 
may  begin  with  a  piping,  inspiratory  sound.  Apnoea  lasting  for  a 
varying  length  of  time  succeeds,  and  is  followed  by  a  loud  or  silent 
expiration.  Apncea  may  a^^pear  first,  and  be  followed  by  several 
noisy  explosive  expiratory  movements,  which  may  be  succeeded  by 
several  noisy  crowing  inspiratory  sounds.  The  picture  is  usually 
that  of  spasm  of  the  glottis  as  first  described,  in  which  the  breathing 
stops  entirely.  The  attack  may  come  on  during  absolute  quiet  or 
during  sleep,  the  onset  of  the  attack  causing  the  child  to  wake. 

The  paroxysms  may  be  brought  on  by  excitement,  a  draught  of 
air,  or  by  pressure  on  the  larynx.     They  are  of  all  degrees  of  severity. 

52 


818  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Some  infants  show  a  form  which  is  very  disquieting.  In  a  fit  of 
crying  the  child  takes  a  number  of  noisy  inspirations  and  expira- 
tions, and  then  stops  breathing,  becomes  cyanosed,  clenches  the  hands, 
and  threatens  to  pass  into  an  eclamptic  paroxysm  (expiratory  apnoea), 
when  suddenly  a  deep  inspiration  occurs  and  the  danger  is  passed. 
Some  cases  of  the  classical  form  have  eclamptic  seizures.  There  may 
be  convulsions,  especially  in  the  form  described  as  expiratory  apnoea. 

One  of  my  cases  was  that  of  an  infant  a  year  old,  one  of  twins. 
The  infant  was  anaemic,  and  showed  marked  signs  of  rachitis  and 
craniotabes.  It  was  in  apparent  health  until  the  eighth  month  of 
infancy,  when  attacks  of  respiratory  apnoea  appeared  at  first  at  inter- 
vals of  three  weeks,  and  finally  daily.  The  infant  during  a  crying- 
siDell  would  -stop  breathing,  become  cyanosed,  the  left  hand  and  arm 
and  lower  extremity  and  muscles  of  the  face  contracted  in  tonic 
spasm,  during  which  the  heart  became  very  slow  in  action  and  irreg- 
ular. The  left-sided  sjDasm  lasted  for  a  few  seconds,  and  then  the 
infant  relaxed  and  quietly  passed  into  a  sleep,  from  which  it  awoke 
in  a  few  moments.  In  all  of  these  cases  there  is  the  ever-present 
danger  that  the  glottis  and  the  muscles  of  respiration,  including  the 
diaphragm,  will  fail  to  relax,  thus  causing  death  with  convulsions. 
The  number  of  attacks  of  spasms  of  the  glottis  may  reach  twenty  or 
thirty  a  day,  or  they  may  be  very  infrequent,  occurring  only  once 
every  few  days,  weeks  or  months.  In  all  the  forms,  including  the 
classical  one  just  detailed,  the  spasm  involves  not  only  the  glottis, 
but  also  the  diaphragm  and  other  muscles  of  respiration.  The  in- 
fants may  show  no  symptoms  after  the  paroxysms.  On  the  other 
hand,  some  infants  seem  to  be  overcome  and  pass  into  a  stupid  state 
lasting  for  fully  ten  minutes.  It  is  difficult  to  estimate  the  degree 
of  consciousness  during  an  attack,  but  even  in  the  mildest  forms 
there  may  be  a  momentary  loss  of  consciousness  (Henoch).  Most 
cases  show  the  facial  and  Trousseau  symptoms  of  tetany  and  in- 
creased irritability  of  the  peripheral  nerves. 

Prognosis. — The  prognosis  of  spasm  of  the  glottis  is  good.  The 
danger  lies  in  the  eclampsia,  during  which  death  may  supervene. 

Diagnosis. — The  diagnosis  is  not  difficult.  There  are  all  degrees 
of  severity  of  the  spasm,  ranging  from  partial  to  complete  closure  of 
the  glottis.  In  the  latter  form  a  rachitic  infant  in  a  paroxysm  of 
crying  is  frequently  heard  to  give  several  inspiratory  crowing  sounds 
without  having  any  further  symptoms.  There  is  a  species  of  laryn- 
geal inco-ordination.  Those  cases  may  at  intervals  develop  typical 
paroxysms.  The  parents  should  be  warned  of  this  possibility.  The 
forms  of  spasm  of  the  glottis  which  have  just  been  described  should 
not  be  confused  with  spasm  or  difficult  breathing  due  to  pressure  of  a 
retropharyngeal  abscess  or  suppurating  gland  upon  the  larynx. 


EPILEPSY.  819 

Complications. — Pertussis  may  complicate  a  case  of  spasm  of  the 
glottis.  Cases  thus  complicated  give  a  grave  prognosis  (Henoch). 
Tetany  has  been  elsewhere  mentioned  as  an  accompanying  condition. 

Treatment. — During  the  Attach. — The  infant  is  carried  to  an  open 
window.  A  draught  of  air  is  allowed  to  blow  in  its  face  or  a  few 
drops  of  water  are  throwm  in  the  face.  This  is  done  to  excite  a  reflex 
relaxation  of  the  glottis.  The  head  should  be  held  low,  as  in  ordi- 
nary eclampsia.  If  relaxation  of  the  glottis  does  not  occur  and  con- 
vulsions set  in,  a  few  drops  of  chloroform  may  cause  the  muscles  of 
respiration  and  those  of  the  glottis  to  relax.  Intubation  and  trache- 
otomy have  been  performed  at  this  crisis,  when  the  breathing  threat- 
ened to  cease  permanently.  If,  however,  as  sometimes  happens,  the 
muscles  of  respiration  are  also  involved,  the  paroxysm  will  occur  with 
the  tracheotomy  tube  in  the  trachea.  Stork  has  published  a  case  in 
which  the  insertion  of  a  tracheotomy  tube  had  not  the  least  influence 
on  the  paroxysms.  This  is  a  very  important  observation,  and  raises 
the  question  of  the  propriety  of  intubating  or  performing  tracheotomy. 
On  the  other  hand,  cases  have  been  intubated  and  resuscitated  with 
artificial  respiration  (Pott). 

In  the  Intervals. — In  the  intervals,  the  treatment  should  be 
chiefly  directed  toward  the  rachitis.  The  feeding  should  be  carefully 
attended  to;  the  infants  should,  if  possible,  be  breast-fed.  Bottle-fed 
infants  should  be  fed  on  raw  milk,  beef-juice,  orange-juice,  cereals, 
and  eggs.  The  medicinal  treatment  which  in  my  hands  has  given 
the  best  results  has  been  the  administration  of  an  albuminate,  or  pep- 
tonate  of  iron  or  manganese  in  full  doses.  To  prevent  the  recur- 
rence of  the  laryngismus  or  apnoeic  attacks,  full  doses  of  the  mixed 
bromides  are  given.  To  an  infant  one  year  of  age  as  much  as  5 
grains  of  the  mixed  bromides  of  sodium,  potassium,  and  ammonium 
are  given  three  times  daily,  and  continued  over  some  period  of  time. 
Under  this  medicinal  treatment  I  have  been  able  to  control  apnoeic 
attacks.  In  my  hands  the  administration  of  phosphorus  has  not 
been  attended  with  any  success. 

Bathing  in  cold  water  has  not  in  my  esiperience  been  productive 
of  good  results. 

EPILEPSY. 

Epilepsy  is  not  a  disease  peculiar  to  infancy  and  childhood.  It  is 
discussed  here  simply  to  emphasize  the  peculiarities  of  the  affection 
as  they  occur  in  children.  It  is  a  true  disease  of  the  nervous  system, 
and  has  nothing  in  common  with  and  no  demonstrable  relationship 
to  infantile  convulsions.  Fifteen  per  cent,  of  the  cases  of  epilepsy 
occur  before  the  fifth  year  of  life.  Henoch  has  seen  a  case  in  an 
infant  one  year  of  age  who  had  convulsions  beginning  with  a  cry 


820  DISEASES  OF  THE  NERVOUS  SYSTEM. 

and  during  which  the  infant  bit  the  tongue.  He  describes  another 
case  in  a  child  three  years  of  age,  in  which  the  attack  began  with 
vertigo.  In  another  case,  in  a  child  three  years  of  age,  the  patient 
fixed  a  point  and  ran  blindly  toward  it.  The  latter  appears  to  have 
been  a  case  of  "procursive  epilepsy." 

Etiology. — According  to  Gowers,  in  two-thirds  of  the  cases  of 
epilepsy  in  children  the  parents  are  neurotic  and  hysterical.  Chorea 
in  the  mother  will  often  manifest  itself  in  epilepsy  in  the  child. 
Infantile  palsy  or  traumatism  is  more  frequently  than  heredity  the 
cause  of  epilepsy.  Epilepsy  following  slight  palsy  is  likely  to  be 
mistaken  for  hereditary  epilepsy. 

Symptoms. — In  children,  as  in  the  adult,  there  are  no  symptoms 
in  the  intervals  between  the  attacks.  Onlj^  such  results  of  attacks 
as  a  bitten  tongue  or  local  traumatism  are  seen.  There  are,  as  in  the 
adult,  two  distinct  forms  of  epilepsy — grand  and  petit  mal — between 
which  there  may  be  all  variations  participating  in  the  peculiarities 
of  both  forms.  In  grand  mal  there  is  the  aura,  sensory  or  psychic ; 
it  is  present  in  a  large  percentage  of  the  cases  in  children. 

Aura. — Baginsky  calls  attention  to  a  case  in  which  epigastric  pain 
was  the  aura  preceding  the  attack.  The  other  forms  of  aura  are 
numbness  and  tingling  of  the  extremities,  general  restlessness  and 
irritability  and  auditory  phenomena  in  which  a  peculiar  cry  of  an 
animal  is  perceived.  There  may  be  a  hissing  sound.  An  aura 
referred  to  the  sense  of  taste  is  very  rare,  and  most  neurologists  do 
not  make  note  of  having  found  it  in  any  case.  In  children  the 
perception  of  peculiar  odors  just  prior  to  the  attack  occurs  as  a  form 
of  aura. 

After  the  aura,  the  attack  begins  with  a  cry  followed  by  sudden 
loss  of  consciousness  and  tonic  or  clonic  spasm  of  the  muscles,  which 
may  be  unilateral,  general,  or  partial.  The  pupils  dilate;  there  is 
spasm  of  the  respiratory  muscles  and  those  of  the  jaw,  as  well  as 
foaming  at  the  mouth  and  biting  of  the  tongue.  The  spasm  then 
relaxes,  the  movements  become  first  clonic  and  then  intermittent, 
there  is  involuntary  passage  of  urine  and  faeces,  and  consciousness 
gradually  returns,  the  patient  passing  into  prolonged  stupor  and  pro- 
found sleep.  Some  of  these  symptoms  may  be  absent,  but  the  loss 
of  consciousness,  dilated  pupils,  spasm,  and  the  succeeding  profound 
sleep  are  constant.  In  the  majority  of  cases,  the  presence  of  any  two 
of  these  will  be  sufficient  for  a  diagnosis. 

Convulsions. — General  convulsions  indicate  hereditary  epilepsy. 
Convulsions  may  at  first  be  partial,  but  in  the  majority  of  cases 
eventually  become  general.  Partial  convulsions  indicate  disease  in 
the  motor  areas.  The  attacks  taking  the  form  of  petit  mal  may  be  so 
slight   as   to   be   mistaken   for   fainting   spells.      Such   attacks   may 


FAVOB  NOCTUENUS.        ■  821 

occur  in  young  children.  One  of  mj  cases  was  in  a  child  of  five  years 
of  age.  An  epileptic  spell  is  momentary ;  a  fainting  spell  is  gradual, 
there  are  no  vasomotor  disturbances,  and  the  pupils  do  not  dilate. 
Henoch  and  others  record  cases  in  which  the  children  momentarily 
stop  the  occupation  in  hand,  stare  into  vacancy,  and  then  recover  them- 
selves without  having  any  recollection  of  the  interruption.  In  other 
cases  there  is  an  irritable  attack  or  mild  maniacal  outbreak.  In  some 
eases  the  child  passes  into  a  state  of  mental  confusion  in  which  it  per- 
forms acts  unconsciously.  Attacks  of  double  consciousness  or  nar- 
colepsis  are  rare  in  children  (Sachs). 

Temperature. — Attacks  of  grand  mal  are  sometimes  associated 
with  a  rise  of  temperature.  A  case  recently  came  under  my  observa- 
tion in  which  a  girl  of  eight  had  as  many  as  forty  convulsive  seizures 
in  twenty-four  hours.  There  was  a  slight  rise  of  temperature  which 
could  not  be  traced  to  any  cause  other  than  the  convulsions.  Thom- 
son and  Oppenheim  have  shown  that  there  are  a  concentric  limitation 
of  vision  and  a  diminution  of  general  sensibility  for  some  time  after 
the  epileptic  attack. 

Diagnosis.  — E23ilei3sy  must  be  differentiated  from  syncope,  hysteria, 
post-hemiplegic  convulsions,  and  tumor  of  the  cerebrum.  The  pecu- 
liarities of  an  attack  of  syncope  and  hysteria  have  been  dilated  upon. 
The  post-hemiplegic  convulsions  will,  in  the  intervals,  reveal  the 
paralyses  and  contractures  with  increase  of  deep  reflexes.  Attacks 
of  convulsions  caused  by  tumor  are  confined  to  groups  of  muscles  if 
the  tumor  is  in  the  motor  area,  and  are  combined  with  optic  neuritis 
if  the  chiasm  is  directly  or  indirectly  the  seat  of  pressure. 

With  tumor,  there  are  in  the  intervals  peculiarities  of  the  gait 
and  epileptic  attacks. 

Treatment. — The  treatment  of  epilepsy  is  essentially  the  same  in 
children  as  in  the  adult  subject. 

PAYOR  NOCTURNUS. 

(Night-terrors.) 

There  are  two  forms  of  this  affection — the  primary  or  idiopathic 
and  the  symptomatic  form.  In  both,  the  children  retire  to  sleep 
and  after  an  hour  or  two  suddenly  awaken  from  deep  slumber  with 
a  shriek  or  cry.  They  are  pale,  greatly  terrified,  and  grasp  at  the 
empty  air.  In  incoherent,  broken  phrases  they  try  to  collect  their 
thoughts.  Some  children  see  terrifying  visions  and  either  cling  to 
the  bystander  for  protection  or  try  to  get  out  of  bed  to  escape  an 
imaginary  danger.  After  being  quieted  the  children  fall  asleep,  and 
when  questioned  the  next  morning  have  no  distinct  recollection  of 
what  has  occurred.     These  attacks  may  occur  every  night  for  days. 


822  DISEASES  OF  THE  XEBrOUS  SYSTEM. 

weeks,  or  months.  They  rarely  occur  twice  in  the  course  of  the 
same  night. 

The  idiopathic  form  of  this  affection  may  occur  in  children  who 
are  naturally  of  a  nervous  temperament  without  any  apparent  excit- 
ing cause.  I  have  seen  it  in  children  who  were  distinctly  the  oppo- 
site of  nervous,  and  who  were  well  nourished  and  good  natured. 
The  night-terrors  may  follow  epilepsy  or  they  may  be  so  severe  as  to 
be  the  exciting  element  in  precipitating  an  attack  of  chorea.  Chil- 
dren sometimes  have  real  hallucinations,  which  may  be  present  even 
during  the  day  (Henoch).  It  may,  however,  be  said  that  halluci- 
nations during  the  day  are  really  not  included  in  the  idiopathic  form. 
This  affection  occurs  chiefly  up  to  the  time  of  second  dentition. 
Forms  of  terror  in  older  children  are  hysterical.  Adenoids  are  sup- 
posed to  be  an  etiological  factor,  but  this  is  doubtful.  It  is  only  in 
the  symptomatic  form  that  children,  after  having  committed  some 
error  in  diet,  awake  with  the  symptoms  above  described. 

Prognosis. — The  prognosis  is  good.  The  affection  never  jDrecedes 
insanity.     It  subsides  under  treatment  or  disappears  spontaneously. 

Treatment. — In  the  symptomatic  form,  the  meals  should  be  so 
arranged  that  the  lightest  repast  is  that  taken  in  the  evening.  In  the 
idiopathic  form,  bromide  of  potassium  is  most  useful.  It  is  admin- 
istered in  one  dose,  an  hour  before  retiring.  The  children  should 
not  be  too  active  mentally  during  the  daytime.  Visitors  should  be 
restricted  to  certain  hours.  Play  and  sport  in  the  open  air  are  indi- 
cated. The  school  tasks  of  older  children  should  be  completed  in  the 
afternoon. 

CHOREA. 

(St.  Vitus'  Dance;  Sydenham's  Chorea.) 

Chorea  is  a  nervous  disease  characterized  by  irregular  involuntary 
movements  or  twitchings  of  some  or  all  of  the  muscles  of  the  body. 
It  is  accompanied  by  muscular  weakness  and  mental  disturbances. 
In  some  cases  there  is  endocarditis. 

Classification. — Chorea  minor  is  an  acute  disease  described  by 
Sydenham.  Chorea  major  is  a  hysterical  disorder;  under  this  head- 
ing are  included  the  chorea  clectrica,  and  the  dancing  mania  with 
rhythmical  motions,  of  the  Middle  Ages. 

Chorea  insaniens  is  the  fatal  form  of  acute  chorea  minor. 

Laryngeal  chorea  is  a  hysterical  affection  (Gowers). 

Choreiform  affections  or  pseudochoreas  comprise  the  cases  of  tic 
convulsif  of  French  writers  and  other  forms  of  habit-spasm,  local 
or  general. 

In  addition   tlierc  are  form>  of  chorea  which   are   symptomatic 


CHOBEA.  823 

or  secondary  to  infantile  palsies.     Hnntington's  chorea  is  a  chronic 
progressive  affection  of  a  hereditary  nature. 

All  these  forms  of  chorea  except  chorea  minor  and  insaniens 
should  be  excluded  from  the  category  of  Sydenham's  chorea. 

The  epidemics  of  so-called  chorea,  occurring  in  schools,  are  prob- 
ably hysterical  disorders  which  are  the  result  of  imitation  and  not 
true  Sydenham's  chorea. 

Frequency  and  Etiology.' — Chorea  is  more  common  among  female 
than  male  children.  Of  554  cases  collected  by  Osier,  YO  per  cent, 
were  of  the  female  sex.  It  rarely  occurs  before  the  fourth  year. 
Starr's  statistics  of  1400  cases  show  8  at  the  third  year.  Cases  are 
recorded  as  occurring  in  newly  born  infants,  but  are  not  accepted  by 
all  authors  as  authentic.  The  disease  is  most  common  from  the  fifth 
to  the  fifteenth  year.  Fifty  per  cent,  of  Starr's  1400  cases  occurred 
before  the  tenth  year,  and  75  per  cent,  from  the  fifth  to  the  fifteenth 
year.  Of  83  cases  of  chorea  occurring  in  my  ambulatory  and  hos- 
pital service,  23  were  of  the  male  and  60  of  the  female  sex.  Ten 
children  were  under  the  age  of  five  years,  and  67  cases  occurred  from 
the  fifth  to  the  tenth  year.  Thus,  the  greatest  frequency  is  at  the 
latter  period.  Only  one  case  occurred  in  a  very  young  child  (two 
and  one-half  years).  The  disease  is  found  in  children  in  all  walks 
of  life. 

Children  of  a  nervous,  ambitious  temperament  with  a  hereditary 
neurotic  history  are  more  prone  to  contract  this  disorder  than  those 
of  a  more  equable  disposition.  It  is  therefore  more  common  in  towns 
and  large  cities  than  in  country  districts.  In  some  cases  there  is  a 
history  of  fright  or  traumatism,  either  immediately  preceding  an 
attack  or  coincident  with  its  onset.  It  is  as  yet  impossible  to  say, 
however,  whether  there  is  any  relation  between  chorea  and  these 
occurrences.  They  may  have  some  influence  in  developing  latent 
tendencies  to  the  disease.  An  attack  will  often  be  initiated  by  a 
scolding  or  chastisement  on  the  part  of  parents.  The  spring  months 
show  the  greatest  number  of  cases,  the  least  number  occurring  in  the 
late  autumn.  There  also  appears  to  be  a  correspondence  in  the  preva- 
lence of  cases  of  chorea  and  rheumatism  at  certain  periods  of  the 
year  (Osier,  Lewis).  The  relation  of  a  condition  of  lymphatism 
(adenoids  or  nasal  catarrh  (Jacobi))  to  true  Sydenham's  chorea  is 
not  generally  eccepted.  Errors  of  refraction  in  the  eyes  also  seem 
to  be  a  predisposing  cause  of  the  outbreak  of  choreic  attacks  (de 
Schweinitz).  These  can  scarcely  be  regarded  as  a  direct  cause  of 
Sydenham's  chorea,  but  acute  articular  rheumatism  may  be  so 
considered. 

Rheumatism  seems  to  run  in  families  in  which  the  children  have 
chorea.     Osier  finds  that  15  per  cent,  of  his  cases  are  of  such  families. 


824  DISEASES  OF  THE  NERVOVS  SYSTEM. 

Of  the  subjects  of  chorea,  fully  21  per  cent,  show  a  history  of  rheu- 
matism (Osier).  These  figures  correspond  more  or  less  to  the  sta- 
tistics of  Townseud,  21  per  cent.;  Starr,  21  per  cent,  in  1400  cases; 
and  my  own  cases,  18  per  cent.  Crandall  gives  the  highest  frequency 
of  rheumatism  in  cases  of  chorea  (54  per  cent.).  In  the  majority 
of  cases  the  rheumatism  precedes  the  chorea  (See).  I  have  seen  one 
ease  of  chorea  preceding  an  attack  of  rheumatism  in  a  child  four  years 
old.  I  believe  that,  with  cases  of  rheumatism  of  the  acute  articular 
type,  there  should  also  be  included  those  of  articular  pains  without 
swelling  of  the  joint.  The  forms  of  rheumatism  with  chorea  giving 
the  so-called  subcutaneous  fibrous  rheumatic  nodules  are  rare  in  this 
country  (Osier). 

Chorea  may  complicate  any  acute  infectious  disease,  such  as  scar- 
let fever,  whooping-cough,  measles,  diphtheria,  typhoid  fever,  and 
forms  of  sepsis.  There  are,  however,  no  definite  data  of  the  exact 
relation,  if  there  be  such,  between  chorea  and  the  infectious  diseases. 
The  theory  that  an  attack  of  any  of  these  diseases  will  cut  short  an 
attack  of  chorea  is  not  borne  out  by  clinical  experience  (Henoch). 

Morlsid  Anatomy. — The  pathology  of  chorea  is  still  incomplete  and 
can  therefore  be  merely  indicated.  Hypersemia  of  the  brain  and 
cord  were  found  by  Pye-Smith  and  Ogle.  Anaemia  and  prolifera- 
tion of  connective  tissue  were  recorded  by  Steiner.  In  the  cases  of 
Meynert  there  was  hyaline  degeneration  of  the  nerve  cells  of  the 
central  ganglia.  Flechsig  mentions  hyaline  degeneration  of  the  len- 
ticular nucleus.  Dana  studied  some  cases  in  which  he  found  hyper- 
semia of  the  brain,  and  degenerative  changes  in  the  walls  of  the 
bloodvessels  of  the  white  substance,  with  perivascular  exudation  and 
accumulation  of  leucocytes.  Jackson  has  advocated  the  embolic 
theory  (endocardial).  At  present  there  is  a  great  preponderance  of 
evidence  in  favor  of  the  infectious  theory.  Berkeley  found  staphylo- 
cocci in  the  blood  in  a  fatal  case  of  chorea.  In  another  case,  Naunyn 
found  cladothrix  in  the  meninges  and  endocardial  vegetations.  It 
is  certain  that  just  as  rheumatism  and  endocarditis  are  infectious 
diseases,  so  chorea  in  many  cases  can  only  be  understood  on  that 
theory.  Cesaris-Demel  has  experimentally  shown  that  the  central 
nervous  system  is  peculiarly  susceptible  to  certain  pathogenic  micro- 
organisms and  their  toxins.  The  staphylococcus  and  its  toxins  when 
injected  experimentally  under  the  dura  mater  cause  the  formation 
of  small  foci  of  inflammation,  and  symptoms  very  similar  to  those 
of  chorea. 

Symptoms. — Children  will  at  the  outset  of  this  disorder  exhibit 
mild  symptoms  of  nervous  irritability,  will  be  cross,  have  outbreaks 
of  peevishness  and  temper,  will  drop  things,  and  be  generally  careless 
in  their  habits.     There  is  sometimes  a  history  of  night-terrors  or 


CHOEEA.  825 

morose  crying  spells.  There  is  likely  to  be  loss  of  appetite  ;  headache 
is  not  uncommon,  and  there  may  be  pains  in  the  limbs  or  joints  and 
general  restlessness.  The  disease  may  begin  in  a  certain  set  of 
muscles,  or  in  the  muscles  of  one-half  the  body  and  thence  spread  to 
the  whole  trunk.  Of  301  cases  of  the  statistics  of  Sachs,  there  was 
hemichorea  or  involvement  of  one  set  of  muscles  in  67.  Of  Starr's 
1400  cases,  951  were  general  and  449  unilateral,  the  right  side  being 
affected  more  frequently  than  the  left.  When  fully  developed,  the 
picture  presented  by  these  patients  is  so  characteristic  as  to  be  easily 
recognized.  On  the  other  hand,  the  popular  notion,  so  prevalent  even 
among  physicians,  that  every  twitching  is  choreic,  has  led  to  grave 
errors.     The  following  are  the  main  symptoms : 

Motor. — The  twitchings  usually  begin  in  the  right  hand,  only 
rarely  in  the  legs.  After  a  time  there  are  incessant,  irregular,  awk- 
ward twitchings  of  all  the  muscles  of  the  body,  which  are  intensified 
by  volition.  If  the  child  is  directed  to  stand  still,  with  the  feet 
together  and  the  arms  and  hands  held  out  at  right  angles  to  the  body, 
the  motions  are  intensified.  If  it  is  told  to  close  the  eyes,  there  is  a 
distinct  swaying  of  the  body.  The  movements  are  not  only  irregular, 
but  awkward.  The  patients  trip  in  walking,  upset  their  food  and 
drink,  and  cannot  button  their  clothing  with  ease.  As  a  rule,  the 
muscular  twitching  ceases  in  sleep,  but  it  may  persist.  The  mus- 
cular power  is  weakened,  although  distinct  paralysis  does  not  occur. 
The  muscle  is  more  paretic  than  paralytic.  Some  children  let  the 
arm  hang  at  the  side.  There  is  wrist-drop  when  the  children  are 
asked  to  hold  out  the  arms.  The  tongue  is  aifected  in  all  cases. 
Sachs  places  much  diagnostic  value  on  the  choreic  movements  of  that 
organ.  When  children  are  asked  to  show  the  tongue,  they  will  pro- 
trude the  organ  with  a  jerk,  then  withdraw  it  and  twist  it  here  and 
there  in  the  cavity  of  the  mouth.  When  the  tongue  is  held  out 
quietly,  fibrillary  twitchings  in  the  organ  may  be  detected.  Elec- 
trical reaction  or  irritability  of  the  muscles  in  chorea  can  be  tested 
only  when  the  disease  is  unilateral.  In  some  cases  there  is  no  change. 
In  others,  according  to  Gowers,  there  is  a  distinct  increase  in  the 
galvanic  and  faradic  irritability  of  nerve  and  muscle.  The  muscles 
of  the  hands,  face,  and  extremities  are  all  involved  in  the  twitchings 
of  the  voluntary  muscles.  The  involuntary  muscles,  such  as  the  car- 
diac muscle,  are  not  affected.  Their  involvement  has  long  been  a 
matter  of  discussion. 

Disturbances  of  Sensation. — Disturbances  of  sensation  are  not 
common.  Children  have  the  arthritic  pains,  l^umbness,  tingling, 
pricking,  and  anEesthesia  of  the  pharynx  are  recorded.  Attacks  of 
multiple  neuritis  and  epileptic  seizures  should  be  regarded  as  compli- 
cations.    The  reflexes  are  not  markedly  affected.     They  may  in  rare 


826 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


cases  be  slightly  diminished  or  increased  (Henoch).  Any  marked 
change  in  the  reflexes  may  be  traced  to  changes  of  an  organic  nature, 
in  the  cord.  The  occurrence  of  headaches  or  eye-strain  as  concomi- 
tant conditions  has  been  referred  to. 

Urine. — The  urine  may  contain  albumin.  Cases  with  nephritis 
as  a  complication  have  been  reported  (Thomas). 

Speech. — The  speech  is  afl^ected  in  25  per  cent,  of  the  cases.  The 
patients  hesitate  and  mumble  their  words  or  there  is  difiiculty  of 
phonation  due  to  inco-ordinate  action  of  the  larynx.  Laryngeal 
chorea,  in  which  there  is  a  distinct  sound  resembling  a  bark,  is  seen 
in  rare  cases.  It  is  classified  by  Gower  as  a  hysterical  disorder,  truly 
choreic.  I  have  never  met  a  case  of  the  kind  in  a  child.  Deglutition 
may  be  affected  because  of  the  muscular  inco-ordination. 

Fig.  185, 


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Chorea.     Recurrent  attack  of  moderate  severity.     Systolic  murmur  over  ttie  aortic  area. 
Fourteen  days  of  the  temperature  is  shown  here.     Child,  twelve  years  of  age. 


Cardiac  Symptoms. — The  cardiac  symptoms  are  the  most  impor- 
tant clinical  feature  of  chorea.  There  is  very  little  doubt  that  in  a 
fixed  proportion  of  cases,  rheumatism  plays  an  important  role  and 
that  the  rheumatic  poison,  whatever  it  may  be,  expends  its  force  upon 
the  endocardium  and  pericardium.  In  20  per  cent,  of  the  cases  of 
Osier  and  in  12  per  cent,  of  Starr's  material,  organic  lesions  of  the 
heart  were  found. 

The  frequency  of  cardiac  disease  in  chorea  varies  as  given  in 
hospital  and  ambulatory  statistics.  The  severer  cases  come  to  the 
hospitals.  The  majority  of  the  ambulatory  cases  are  mild.  Thus  39 
per  cent,  of  my  hospital  cases  showed  a  cardiac  lesion  (endocarditis), 
while  only  1-3  per  cent,  of  the  ambulatory  cases  were  similarly  affected. 
There. would  thus  be  an  average  of  2G  per  cent,  of  both  hospital  and 
ambulatory  cases.  The  lesions  in  simple  chorea  referable  to  the 
endocardium  usnally  affect  the  mitral  valve.  Of  17  valvular  lesions, 
14  occurred  at  the  mitral  valve  (systolic).  The  aortic  valve  was 
affected  in  3  cases  (Fig.  185).  Pericarditis  occurred  in  one  of  my 
cases.  In  the  majority  of  cases  in  which  there  was  endocarditis 
either  the  patient  or  the  parents  gave  a  rheumatic  history. 


CHOBEA. 


827 


On  the  other  hand,  not  all  murmnrs  of  the  heart  are  organic.  In 
9  per  cent,  of  Starr's  1400  cases,  there  were  functional  murmurs 
heard  at  the  base  and  over  the  pulmonic  area,  early  or  late  in  the  dis- 
ease. A  gentle  blowing  at  the  apex  which  is  heard  to  the  left  of  the 
sternum  and  is  not  conducted  into  the  axilla  or  arteries  is  heard  late 
ill  the  affection,  and  is  undoubtedly  hsemic  or  myocarditic  (Osier). 
I  have  heard  these  murmurs  in  many  cases  and  have  come  to  the 
same  conclusion.  Murmurs  may  also  arise  at  the  tricuspid  orifice. 
The  organic  murmurs  are,  as  stated  above,  produced  at  the  mitral 
orifice  in  the  greatest  number  of  cases.  They  may  arise  in  the  course 
of  the  disease  or  may  appear  during  a  relapse.  Such  cases  will  show 
a  temperature  (Fig.  186). 


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Chorea.  Endocarditis.  Previous  attack  six  months  prior  to  the  present  illness, 
which  was  of  five  weeks'  duration  before  the  above  observation.  Pains  in  the  .ioints, 
especially  the  knee.  This  curve  shows  two  weeks  of  the  endocarditis.  Recovery.  Female 
child,  five  years  of  age. 

The  temperature  may  after  a  time  become  normal,  and,  in  a  week 
or  more,  while  the  chorea  is  still  in  progress  there  may  be  a  rise  last- 
ing for  a  day  or  more,  after  which  it  may  then  again  subside  to  the 
normal.  The  temperature  may  be  but  a  fraction  of  a  degree  above 
the  normal,  and  the  diurnal  course  may  be  distorted  or  subnormal 
fJlirgensen).  There  is  thus  clinically  a  true  endocarditis.  This 
form  of  endocarditis  may  pave  the  way  for  future  chronic  valvular 
disease.  Under  the  heading  of  Chorea  Insaniens,  I  have  noted  two 
fatal  cases  of  this  form  of  heart  disease.  Chorea  of  the  heart  muscle 
is  not  clinically  recognized.  Pericarditis  with  endocarditis  may  occur 
in  cases  of  recurrent  chorea.  I  have  seen  two  such  cases.  Func- 
tional disturbances  such  as  palpitation  and  arrhythmia  also  occur. 

Temperature. — There  are  some  forms  of  chorea  minor  without 
any  signs  of  endocarditis  which  run  a  course  with  a  slight  tempera- 
ture, the  cause  of  which  is  undetermined.  Some  authors  think  that 
there  may  be  a  latent  endocarditis  in  these  forms  of  chorea  (Henoch). 
If  endocarditis  is  present,  there  may  be  a  temperature  only  slightly 
above  normal.  In  most  cases  of  chorea  there  is  no  temperature  (Fig. 
187).  Fatal  cases  of  chorea,  with  few  exceptions,  show  signs  of  endo- 
carditis. Osier  has  made  a  study  of  80  such  cases,  and  found  only 
5  which  postmortem  did  not  show  changes  in  the  valves. 


828  DISEASES  OF  THE  NEBTOUS  SYSTEM. 

The  mental  symptoms  are  in  some  cases  marked.  The  patients 
show  apathy  and  depression.  The  children  often,  while  they  are 
under  treatment,  have  spells  of  mental  depression  and  fits  of  crying. 
It  is  only  in  the  cases  of  insaniens  that  delirium  occurs.  In  severe 
cases  there  is  a  period  of  more  or  less  mental  depression,  extending 
far  into  convalescence. 

Diagnosis. — The  diagnosis  of  chorea  minor  is  not  difficult  in  the 
majority  of  cases.  The  picture  is  a  very  characteristic  one.  There 
are  slight  twitchings,  which  so  closely  resemble  habit  movements  that 
it  is  not  easy  to  come  to  a  conclusion  in  regard  to  them.  Sachs 
thinks  that  the  twitchings  of  the  tongue  are  a  means  of  distinguish- 


FiG.  187. 


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Chorea,  without  endocarditis,  two  months  in  duration.     No  rheumatic  history. 

child,  nine  years  of  age. 


Female 


ing  the  mild  cases  of  chorea  from  cases  of  habit  movements.  If  the 
patient  is  told  to  show  the  tongue,  the  tremors  and  twitchings  of  that 
organ  and  the  facial  grimaces  at  once  become  marked.  The  move- 
ments of  the  muscles  are  more  rhythmic  in  hysteria  than  in  chorea. 
True  Sydenham's  chorea  should  be  distinguished  from  the  chorea 
and  athetoid  movements  seen  in  cases  of  infantile  palsy.  The  his- 
tory of  the  cases,  the  paralysis,  the  condition  of  the  reflexes  and  the 
contractures  will  be  of  assistance  in  making  a  diagnosis.  True  Syden- 
ham's chorea  should  also  be  differentiated  from  cases  of  tic  convulsif 
and  habit  movements.  A  diagnosis  of  chorea,  made  in  a  case  which 
has  lasted  for  a  year  or  more,  is  open  to  doubt. 

Duration.  ■ — The  duration  of  chorea  is  variable.  It  may  last  from 
three  to  ten  weeks,  and  may  recur.  The  recurrent  attacks  are  not 
necessarily  any  more  severe  than  previous  attacks.  Fully  one-third 
of  the  cases  in  some  statistics  show  two  or  more  attacks.  Of  Starr's 
1400  cases,  365,  or  26  per  cent.,  had  relapses.  One  case  had  nine 
attacks. 

Prognosis.— The  prognosis  of  chorea  minor  is  very  good.  Recovery 
is  the  rule,  but  in  exe('])lional  cases  it  may  be  delayed  for  fully  three 
months. 


CHOEEA.  829 

Treatment. — The  treatment  of  chorea  consists  at  first  in  giving 
the  patient  perfect  rest  and  quiet  surroundings.  Children  are  put 
to  bed  and  kept  free  from  excitement.  I  do  not  think  it  necessary 
to  isolate  them,  and  it  is  not  wise  to  do  so,  since  they  may,  under  such 
treatment,  become  melancholic.  An  ordinary  amount  of  quiet,  such 
as  is  prescribed  in  cardiac  cases,  is  all  that  is  usually  necessary.  The 
patient  may  be  allowed  to  look  at  picture-books,  but  not  to  study  or 
to  read.  A  simple,  easily  assimilable  diet  is  indicated,  milk  and  eggs 
being  the  chief  articles.  A  warm  bath  is  given  daily  and  the  spine 
sponged  with  cool  water,  as  some  authors  recommend.  I  have  not 
found  this  necessary  in  all  cases,  and  would  advise  it  to  be  omitted  if 
the  children  strongly  object  to  it.  Massage  is  of  great  value  with 
anaemic  children  in  whom  the  circulation  is  below  the  average  and 
who  have  no  cardiac  disease  and  no  temperature. 

Drugs.- — Fowler's  solution  is  used  almost  as  a  routine  remedy  in 
these  cases.  In  my  experience  its  curative  effects  are  doubtful.  I 
therefore  prefer  to  give  it  in  small  tonic  doses,  rather  than  risk  the 
ill  effects  of  large  dosage.  There  are  cases  in  which  any  attempt  to 
administer  it  causes  vomiting,  and  which  therefore  do  much  better 
without  it.  In  any  case  it  should  be  well  diluted.  In  this  way  larger 
doses  can  be  given  for  a  greater  length  of  time  than  would  otherwise 
be  possible. 

Cases  w'hich  show  recent  or  old  endocarditis  or  which  have  artic- 
ular pains  should  receive  antirheumatic  treatment.  Alkalies  to  keep 
the  bowels  open,  alkaline  baths,  and  sodium  salicylate  are  the  reme- 
dies in  use  in  these  cases. 

If  there  is  great  restlessness,  bromides  should  be  resorted  to.  It 
is  a  very  good  plan  to  combine  the  bromides  of  sodium,  potassium, 
and  ammonium  in  one  mixture.  Trional  given  in  grain  v  (0.3) 
doses  several  times  daily  is  a  very  good  remedy  in  this  set  of  cases, 
especially  if  there  is  wakefulness  at  night. 

If  on  account  of  the  loss  of  appetite  and  general  mental  depres- 
sion it  is  not  possible  to  give  any  drugs,  the  children  are  simply  kept 
quit  and  given  a  nutritious  diet.  They  frequently  recover  without 
the  help  of  any  drugs.  In  ordinary  cases  there  is  no  necessity  of 
using  opiates,  such  as  codeine.  Antipyrin  in  grain  v  (0.3)  doses  has 
been  recommended.  I  have  not  found  it  better  than  other  remedies. 
Children  who  have  recovered  should  be  kept  quiet  for  fear  of  a  recur- 
rence of  symptoms.  This  is  especially  true  of  cases  in  which  the 
heart  has  been  the  seat  of  a  recent  endocarditis. 

Chorea  Insaniens. — Chorea  insaniens  is  a  term  applied  to  the 
severest  form  of  chorea.  A  large  number  of  these  cases  run  their 
course  with  delirium  and  high  fever.  It  occurs  especially  in  female 
subjects.     At  the  outset  there  may  appear  to  be  nothing  more  than 


830 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


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He  had  chronic  cardiac  disease. 


an  ordinarily  severe  chorea,  but  the 
jDatient  rapidly  becomes  worse.  De- 
lirium with  hallucinations  sets  in, 
finally  giving  way  to  incoherency  and 
mania.  The  patients  are  .in  inces- 
sant motion  and  do  not  sleep  at  night. 
The  fever  may  mount  as  high  as  107  ^ 
F.  (41.6°  C).  The  cases  are  in 
many  instances  fatal.  Osier  gives  a 
resume  of  some  fatal  cases.  I  have 
seen  2  fatal  cases  of  this  form.  One 
case  occurring  during  my  service  as 
interne  at  Bellevue  Hospital  was  that 
of  a  girl  of  twelve,  who  died  with 
symptoms  very  similar  to  those  of 
acute  mania.  Another  case,  seen  re- 
cently, was  a  boy  of  ten  years,  who 
had.  for  two  years  previously  suffered 
from  '  ordinary  chorea.  He  had  a 
mitral  regurgitant  murmur.  Two 
weeks  before  his  death  he  was  suffer- 
ing from  a  mild  recurrence  of  the 
chorea.  While  in  that  state  he  was 
aperated  on  for  adenoids  and  enlarged 
tonsils.  Chloroform  was  adminis- 
tered. Three  days  after  the  opera- 
tion the  boy  was  taken  with  a  chill, 
the  chorea  became  worse,  and  there 
was  fever.  Examination  of  the  heart 
showed  endocarditis  and  pericarditis 
with  dilatation  of  the  left  ventricle. 
In  the  second  week  the  boy  became 
delirious  and  did  not  sleep  at  night. 
He  complained  constantly  of  pain  in 
the  prsecordium  and  tossed  in  bed. 
He  died  two  weeks  after  the  onset  of 
the  disease.  There  was  throughout  a 
high  febrile  movement.  A  third  case 
was  that  of  a  boy  six  years  of  age, 
whose  temperature-curve  is  herewith 
ai^pended  (Fig.  188).  This  case 
occurred  in  my  hospital  service.  It 
was  the  boy's  third  attack  of  chorea. 
In  the  final  attack  there  was  compli- 


FOBMS  OF  TIC.  ■  831 

eating  j^ericarditis  with  effusion.  The  delirium  was  constant  and 
the  choreic  movements  incessant.  He  went  into  a  typhoid  state,  but 
recovered,  his  mental  faculties,  however,  being  shattered.  During 
the  course  of  the  pericarditis  there  was  a  polynuclear  leucocjtosis, 
and  45  per  cent,  hsemoglobin. 

These  cases  are  to  be  differentiated  from  cases  of  severe  simple 
chorea,  in  which  the  movements  are  so  incessant  that  the  j)atients 
can  with  difficulty  be  kept  in  bed.  In  simple  chorea  there  is  no 
delirium  and  there  is  a  period  of  quiescence  at  night. 

Treatment. — The  treatment  of  chorea  insaniens  is  symptomatic. 
The  delirium  and  incessant  restlessness  are  controlled  with  bromide 
of  potassium,  or  sodium  combined  with  chloral  hydrate.  The  use  of 
morphine  is  indicated  in  cases  in  which  the  chloral  and  bromides  are 
ineffectual.  Complicating  endocarditis  and  pericarditis  are  treated 
as  when  primary. 

FORMS  OF  TIC. 

(Habit  Movements  or  Spasms.) 

This  affection  is  mentioned  in  this  place  to  emphasize  the  impor- 
tance of  sharply  differentiating  its  forms  from  true  Sydenham's 
chorea.  Tic  is  defined  by  Growers  as  a  habitual  and  conscious  con- 
vulsive movement  of  one  or  more  of  the  muscles  of  the  body,  repro- 
ducing some  reflex  or  automatic  movement  normal  to  the  individual. 
Osier  has  classified  the  forms  of  tic.  There  is  first  the  ordinary 
form,  in  which  young  people  or  children  develop  a  spasm  of  a  group 
of  muscles,  generally  of  the  face.  Children. do  not  have  the  form 
known  as  idioiDathic  spasm  of  adults  in  which  the  lower  extremities 
are  involved.  There  is  contraction  of  a  group  of  facial  muscles,  such 
as  the  orbicularis  or  the  muscles  about  the  nose.  There  are  other 
forms  of  tic  in  which  mental  disturbances  and  explosive  utterance  of 
words  or  syllables  are  prominent  features.  If  the  words  are  of  an 
obscene  character,  the  condition  is  called  coprolalia.  In  other  cases 
the  patients  repeat  words  or  sentences  (echolalia).  The  so-called 
laryngeal  barks  of  a  hysterical  nature  are,  according  to  most  observers, 
to  be  classified  as  forms  of  tic,  and  not  as  laryngeal  chorea. 

There  is  a  fourth  class,  which  includes  those  cases  in  which  the 
subject  before  proceeding  to  any  definite  act,  such  as  writing,  feels 
impelled  to  blow  on  the  fingers,  pinch  the  nose,  or  strike  the  head  or 
thorax.  These  actions  may  be  regarded  as  harmless  tricks.  In 
another  form  of  tic  the  patients  feel  impelled  to  touch  objects,  such 
as  the  floor  or  wall  (delire  de  toucher  of  French  writers). 


832  DISEASES  OF  TEE  NEBFOUS  STSTEM. 

RHYTHMIC  MOVEMENTS  OF  THE  HEAD  ASSOCIATED  WITH 

NYSTAGMUS. 

(Head-nodding ;  Spasmus  Nutans;  Gyrospasm.) 

N'ystagmus  alone  is  quite  frequently  observed  in  infancy  and 
childhood. 

Khythmic  movements  of  the  head  associated  vdth  nystagmus  con- 
stitute an  uncommon  affection. 

The  derangement  is  functional  and  occurs  in  poorly  nourished 
and  rachitic  infants  whose  nerve  resistance  is  diminished.  The 
majority  of  cases  give  a  history  of  some  preceding  illness,  in  the 
course  of  which  the  infant  has  suffered  from  convulsions.  The 
mothers  may  be  of  a  nervous  temperament.  The  phenomenon  which 
at  once  attracts  attention  is  a  rhythmic  oscillation  of  the  head  in  a 
horizontal  or  vertical  direction,  or  both.  On  close  examination  it 
will  also  be  noticed  that  the  eyes  have  a  horizontal,  vertical,  or  oblique 
form  of  nystagmus.  Ebert,  Cahen,  Caille,  Gee,  Hadden,  and  Lewi 
have  studied  these  cases.  Lewi  reported  some  cases  from  my  clinic. 
The  ages  of  the  infants  ranged  from  three  to  eighteen  months.  The 
movements  were  augmented  when  the  infant  focused  some  attractive 
object. 

The  nystagmus,  if  not  marked,  may  be  made  apparent  by  holding 
an  object  to  the  right  and  upward  for  the  infant  to  focus.  Lewi  as 
well  as  Caille  found  that  the  nystagmus  ceased  when  the  infant  was 
blindfolded.  In  one  case  the  movements  continued  when  the  infant 
was  in  the  recumbent  posture.  The  eye  and  head  movements  were 
not  synchronous.  As  a  rule  the  eye  movements  were  the  more  rapid. 
These  observers  did  not  agree  with  Hadden  in  finding  that  forcible 
restraint  of  the  head  stopped  the  nystagmus.  I  have  been  accus- 
tomed to  see  a  number  of  these  cases  yearly.  Some  of  the  infants 
are  quite  bright  and  well  nourished.  This  statement  agrees  with  that 
which  Thomson  recently  made.  Three-fourths  of  the  cases  are  under 
the  age  of  twelve  months  (Thomson). 

Etiology. — The  etiology  of  the  affection  is  obscure.  It  is  usually 
coincident  with  the  period  of  dentition,  but  may  appear  as  early  as 
the  third  month.  Some  of  the  infants  live  in  dark,  squalid  quarters, 
and  the  affection  has  been  attributed  to  eye-strain  caused  by  the  in- 
fant's attempts  to  fix  a  light  as  it  lies  in  its  crib.  This  theory  would 
make  the  affection  appear  similar  to  that  frequently  seen  in  miners 
(IMagnus).  Some  of  the  patients  that  I  have  seen  lived  in  well- 
lighted  quarters. 

Rachitis  was  present  in  most  of  my  cases.  Thomson's  expe- 
rience was  similar.  Henoch  gives  a  physiological  explanation  of  the 
combination  of  nystagmus  with  the  rotary  movements  of  the  head. 


EYDEOCEPHALUS.  833 

by  pointing  out  that  the  root  nuclei  of  the  nerves  of  the  muscles  of 
the  neck  and  throat  which  rotate  the  head  are  adjacent  to  the  ocular 
nuclei,  and  that  any  irritation  of  one  set  of  nuclei  may  affect  the 
other.     This  explanation  has  been  generally  accepted. 

Treatment. — The  cases  as  a  rule  recover.  They  are  given  outdoor 
air,  correct  food,  and  a  general  course  of  treatment  for  the  rachitis. 
Phosphorus  is  given  as  in  rachitis.  I  have  also  prescribed  the  bro^ 
mides  of  potassium  and  sodium,  grains  v  (0.35)  three  times  daily. 
The  cases  certainly  improved  in  time.  The  blindfolding  suggested  by 
Caille  only  stops  the  rhythmic  movements  of  the  head  temporarily. 

HYDROCEPHALUS. 

(Dropsy  of  the  Brain.) 

Hydrocephalus  or  dropsy  of  the  brain  is  an  abnormal  accumula- 
tion of  fluid  in  the  subdural  space,  or  in  the  ventricles  of  the  brain. 
In  the  former  case  there  is  external,  in  the  latter  internal  hydroceph- 
alus. Hydrocephalus  may  be  acute  or  chronic.  It  may  also  be  con- 
genital, secondary,  or  primary.  The  last-named  form  occurs  in  adult 
subjects  (Delafield).  Acute  hydrocephalus  is  described  under  the 
caption  of  Meningitis  Serosa. 

Congenital  Internal  Hydrocephalus. — The  accumulation  of  fluid 
begins  in  utero.  The  quantity  at  birth  may  be  small  and  may  after- 
ward increase.     It  may  be  large  enough  at  birth  to  obstruct  delivery. 

Etiology. — The  causes  of  the  condition  are  unknown.  Alcohol- 
ism, syphilis,  and  tuberculosis  of  the  parents  have  been  regarded  as 
predisposing  causes,  but  infants  thus  affected  may  be  born  of  per- 
fectly healthy  parents.  Sometimes  several  infants  with  this  malady 
are  born  to  one  mother. 

Mortid  Anatomy. — The  quantity  of  fluid  accumulated  in  the  ven- 
tricles varies.  The  fluid  is  perfectly  clear  and  has  a  specific  gravity 
of  from  1001  to  1009.  It  contains  a  trace  of  albumin  and  some- 
times urea,  sodium  chloride,  and  cholesterin.  The  weight  may  reach 
twenty-seven  pounds.  The  fluid  distends  the  lateral  ventricles,  the 
third  and  fifth  ventricles,  and  the  fourth  to  a  less  degree.  The  cen- 
tral canal  of  the  cord  may  be  dilated  (Delafield).  The  corpus  callo- 
sum  is  displaced  upward.  The  thickness  of  the  cerebral  substance 
may  be  reduced  to  a  few  millimetres.  The  convolutions  may  be 
obliterated,  as  may  also  the  basal  ganglia.  The  aqueduct  of  Sylvius 
is  dilated.  The  white  matter  of  the  brain  suffers  most.  The  mem- 
brane of  that  organ  may  be  normal.  The  ependyma  may  be  thick- 
ened and  granular. 

Symptoms. — The  symptoms  are  the  gradually  increasing  size  of 
the  head  and  the  development  of  idiocy  and  paralyses  as  a  result  of 

53 


834 


DISEASES  OF  THE  XEBVOUS  SYSTEM. 


internal  pressure  on  the  nervous  structures.  The  cranium  enlarges 
so  that  it  becomes  disproportionate  to  the  face,  -^hich  remains  small. 
There  is  bulging  of  the  occipital  and  frontal  regions.  The  orbital 
plates  take  an  oblique  direction,  causing  the  eje-s  to  assume  a  pecu- 
liar stare  (Fig.  189).  The  sclera  is  seen  exposed  above  the  cornea. 
The  eyes  are  directed  downward  and  are  only  partially  covered  by 
the  eyelids.  The  sutures  are  forced  apart  and  the  fontanelles  are 
widely  open.  The  anterior  fontanelle  bulges  and  pulsates  visibly. 
The  cranial  bones  may  here  and  there  show  areas  of  thinness  resem- 
bling those  seen  in  craniotabes.  The  lambdoid  suture  is  flattened 
and  the  greatest  diameter  is  across  the  temples.  The  head  may 
attain  an  enormous  size,  the  child  being  unable  to  hold  it  upright. 


Fig.  189. 


Congenital  internal  hydrocephalus.     Infant,  nine  months  of  age. 


The  hair  is  scanty  and  dry.  There  may  be  strabismus,  palsies,  con- 
tractures, and  convulsions.  The  eyes  may  not  be  on  a  level.  Blind- 
ness may  result.  When  the  disease  is  progressive,  idiocy  develops. 
The  children  are  very  weak. 

Diagnosis. — Hydrencephaloid  or  spurious  hydrocephalus  is  a  con- 
dition which  supervenes  in  acute  exhausting  states,  such  as  that  which 
follows  diarrhceal  diseases.  There  is  neither  bulging  of  the  fonta- 
nelles nor  enlargement  of  the  head.  The  fontanelle  is  depressed  and 
the  eyes  are  sunken.  In  certain  forms  of  rachitis  which  are  accom- 
panied by  craniotabes  and  cranial  bosses  ov(  r  the  parietal  and  frontal 
bones,  there  is  frequently  a  very  mild  form  of  hydrocephalus.  This 
condition  is  rarely  progressive.     It  may  be  distinguished  from  true 


EYDEOCEPHALUS.  835 

congenital  hydrocephalus  by  the  absence  of  progressive  enlargement 
of  the  skull.  The  sutures  may  be  patent,  especially  that  between  the 
parietal  and  frontal  bones.  The  signs  of  rachitis  are  present  else- 
where, and  the  children  are,  in  contrast  to  the  semi-idiotic  subjects 
of  hydrocephalus,  very  bright. 

In  differentiating  congenital  internal  hydrocephalus  from  the 
external  form  the  history  is  of  gTeat  value.  External  hydrocephalus 
appears  at  birth  and  is  not  accompanied  by  bulging  of  the  frontal 
and  occipital  bones.  Mental  deficiency  is  present  from  the  outset. 
Late  in  the  disease  it  may  be  impossible  to  disting-uish  between  the 
two  forms.  A  form  of  cranial  syphilis  is  mentioned  by  Gowers  as 
causing  cranial  enlargement,  which,  however,  is  never  so  marked  as 
in  congenital  hydrocephalus. 

The  diagnosis  of  congenital  chronic  internal  hydrocephalus  rests 
on  the  progressive  enlargement  of  the  cranium,  the  bulging  in  the 
occipital  and  frontal  regions,  and  the  flattening  across  the  lambdoid 
suture.  Acquired  hydrocephalus  rarely  appears  before  the  tenth 
month  (Ireland). 

It  is  sometimes  of  interest  to  distinguish  at  autopsy  between  the 
congenital  and  acquired  forms  of  hydrocephalus.  Meynert  has  shown 
that  in  congenital  hydrocephalus  the  lateral  ventricles  are  dilated  in 
their  long  diameters ;  the  posterior  horn  is  dilated,  so  that  it  reaches 
within  a  few  millimetres  of  the  cranium.  Acquired  hydrocephalus, 
on  the  contrary,  usually  dilates  the  ventricles  in  their  vertical  and 
cross  diameters. 

Prognosis. — Hydrocephalus  is  one  of  the  most  fatal  nervous  affec- 
tions. There  are  mild  forms  in  which  the  accumulation  of  fluid 
ceases  after  a  certain  time  and  recovery  takes  place,  the  intelligence 
being  either  slightly  weakened  or  normal.  In  some  cases  the  enlarge- 
ment continues  and  death  ensues  from  marasmus.  In  other  cases  the 
head  becomes  of  enormous  size ;  the  increase  of  fluid  ceases ;  the  fon- 
tanelles  and  sutures  close ;  the  unfortunate  subjects  have  an  enormous 
ossified  skull,  which  they  are  unable  to  hold  upright.  They  are  par- 
tially idiotic  or  imbecile.  They  often,  however,  have  a  slight  degree 
of  intelligence,  and  may  recite  lessons,  but  are  helpless  in  every  way. 

Treatment. — The  treatment  of  congenital  internal  hydrocephalus 
is  alone  of  interest  to  the  physician.  The  condition  is  hopeless. 
The  injection  of  solutions  of  iodine  (Morton's  fluid)  has  been  tried 
with  doubtful  results.  I  have  had  2  cases  in  which  the  ventricles 
were  aspirated,  fluid  was  withdrawn,  and  the  head  bandaged.  The 
operations  were  performed  by  an  expert  under  antiseptic  precautions. 
In  neither  case  was  the  course  of  the  disease  affected.  The  fluid 
reaccumulated.  Both  patients  died.  I  have  performed  lumbar 
puncture  on  several  cases,  repeated  at  short  intervals  without  perma- 


836 


DISEASES  OF  THE  NEEVOUS  SYSTEM. 


uent  benefit.  In  one  case  the  temperature  rose  to  108°  F.  (42.2° 
C),  Cheyne-Stokes  respiration  set  in,  and  the  patient  died. 

Cases  in  which  Keen,  of  Philadelj)hia,  inserted  a  permanent 
drain  did  not  give  encouraging  results.  Pott  had  an  equally  discour- 
aging experience  with  that  mode  of  treatment.  Iodide  of  potassium 
administered  internally  is  of  doubtful  value.  In  estimating  the  re- 
sults of  treatment,  it  should  not  be  forgotten  that  a  small  percentage 
of  cases  cease  to  progress  at  a  certain  stage  of  the  disease,  and  make 
a  tolerably  fair  spontaneous  recovery. 

External  Hydrocephalus. — External  hydrocephalus  may  be  ac- 
quired  or   congenital.      If   congenital,    it   follows   an   intra-uterine 

Fig.  190. 


External  hydrocephalus.      (Author's  case.) 


])achynieningitis  or  may  take  place  because  of  the  rudimentary  state 
of  the  cerebrum  (hj^drocephalus  anencephaliquc).  External  hydro- 
cephalus may  be  acquired,  in  which  case  it  follows  a  pachymeningitis 
interna  ha-morrhagica  or  is  the  result  of  a  meningitis  in  infancy. 
The  congenital  form  of  external  hydrocephalus  is  very  rare.  Bokai 
records  a  case  in  an  infant  nine  months  of  age.  There  was  an  accu- 
7nulation  of  fluid  between  the  dura  and  pia  mater.  Both  membranes 
and  the  falx  were  thickened,  but  there  were  otherwise  no  signs  of 


AMAVBOTIC  IDIOCY.  837 

inflammation.  The  infant  had  spastic  symptoms.  The  diagnostic 
points  in  these  cases  are  the  uniform  enlargement  of  the  head  and  the 
bulging,  especially  in  the  temporal  region.  The  axes  of  the  eyes 
remain  normal,  the  condition  of  those  organs  differing  in  that  respect 
from  that  seen  in  internal  hydrocephalus,  in  which  they  are  depressed 
downward.  There  may  be  slight  exophthalmos.  In  Lewis  Smith's 
case  the  axes  of  the  eyes  were  normal. 

In  some  cases  of  external  hydrocephalus  the  head  attains  an 
enormous  size.  The  disease  cannot  then  be  distinguished  from  the 
chronic  internal  form.  In  one  of  my  cases  external  hydrocephalus 
followed  meningitis.  The  head  was  uniformly  large,  the  bulging 
over  the  temporal  region  being  marked.  The  axes  of  the  eyes  were 
normal.     The  intelligence  was  low. 

In  some  cases  of  external  hydrocephalus  there  is  a  slight  internal 
hydrocephalus. 

AMAUROTIC  IDIOCY. 

(Family  Idiocy — Sachs.) 

This  disease  was  first  described  by  Warren  Tay,  an  English  ocu- 
list, in  1881.  Among  other  symptoms,  he  noticed  peculiar  changes 
in  the  fundus  of  an  infant  suffering  from  the  affection.  We  owe  the 
more  extensive  study  of  the  affection  to  the  American  neurologist 
Sachs,  who  described  his  first  case  in  188Y,  not  knowing  that  Tay  and 
Kingdon  had  previously  published  theirs.  Sachs  has  collected  27 
cases  in  the  literature,  his  own  cases  being  included  in  the  number. 
I  have  published  2  cases  and  have  since  seen  25  cases. 

Etiology. — The  etiology  of  the  affection  is  still  unknown.  Alco- 
holism and  syphilis  do  not  appear  to  be  very  closely  connected  with 
its  occurrence.  It  appears  to  run  in  families.  Frequently  two  or 
more  children  in  a  family  are  affected. 

There  is  certainly  a  so-called  neuropathic  predisposition.  It  is 
a  disease  which  affects  more  frequently  children  of  the  Jewish  race ; 
thus  of  86  cases  collected  by  TIerveroch  in  1904,  61  belonged  to  this 
class. 

Course. — The  course  of  the  disease  is  slow  and  progrediant.  There 
is  the  gradual  beginning  in  apparently  healthy  children.  In  the 
cases  thus  for  reported  there  has  been  no  neglect  in  the  hygiene  and 
many  if  not  most  of  the  infants  have  been  breast-fed. 

Forms.- — There  are  now  two  well-recognized  forms  of  the  affec- 
tion. The  infantile  form  affects  infants  from  the  third  month  of 
infancy  and  results  in  their  death  about  the  end  of  the  second  or  the 
third  year  of  childhood.  The  juvenile  form  has  been  described  by 
Higier,  Freud,  Spielmeyer,  and  Vogt.     It  affects  children  from  the 


838  DISEASES  OF  THE  NERVOUS  SYSTEM. 

sixth  to  the  fourteenth  year  and  like  the  infantile  form  is  slowly 
progressive,  leading  to  marasmus  and  death.  The  symptomatology 
and  morbid  anatomy  of  both  forms  are  strikingly  similar,  with  a  dif- 
ference which  will  be  pointed  out  later. 

Morbid  Anatomy. — The  morbid  anatomy  of  amaurotic  idiocy  is 
certainly  unique  in  the  fact  that  all  cases  show  the  same  changes  and 
these  are  distributed  throughout  the  whole  nervous  system.  The 
nerve-cells  are  most  affected  and  the  changes  are  such  as  to  stamp 
the  disease  an  entity  in  neuropathology.  There  is  not  a  normal  cell 
to  be  found  in  the  whole  nervous  system.  Tay  and  Kingdon,  Sachs, 
Van  Giesen,  Hirsch,  Schaffer,  and  Vogt  have  studied  these  changes 
and  their  results  correspond  in  the  main.  There  is  a  degeneration  of 
the  ganglion  cells  throughout  the  gray  matter  of  the  brain  and  cord. 
This  consists  in  a  swelling  of  the  cell  and  an  extraordinary  trans- 
parency and  pallor  of  the  cell-body.  The  form  of  the  cell  is  changed 
into  an  ampulla-like  mass,  the  nucleus  of  the  cell  is  displaced  toward 
the  periphery  of  the  body  and  the  ISTissl  granulations  have  almost 
entirely  disappeared.  In  some  cells  a  few  granules  are  left  in  the 
cell-body. 

The  general  characteristics  of  the  nerve-cell  are  lost ;  the  swelling 
of  the  cell  has  increased  its  volume  several  times.  There  is  chromol- 
ysis.  In  the  final  stage  of  the  degeneration  the  cell  does  not  show 
any  nucleus.  It  is  pale  and  colorless,  the  nucleolus  alone  is  indi- 
cated and  the  original  form  of  the  cell  is  distorted.  There  is  destruc- 
tion of  the  dendrites  and  breaking  off  and  degeneration  of  the  axis- 
cylinder  process.  The  axis-cylinder  may  show  some  intact  fibrillse; 
the  dendrites  show  some  fibrillation,  but  only  in  spots.  The  den- 
drites are  much  swollen.  The  glia  shows  a  marked  proliferation  of 
cells  and  fibres.  The  pia,  connective  tissue,  and  bloodvessels  show 
nothing  abnormal.  The  above  changes  are  seen  in  the  brain  and 
cerebellum  and  in  the  cord  and  medulla  oblongata.  The  greatest 
changes  are  found  especially  in  the  cells  of  the  anterior  and  antero- 
lateral horns  of  gray  matter  of  the  cord. 

Symptoms. — The  symptoms  are  divided  as  follows:  (1)  Psy- 
chical disturbances  tending  to  complete  idiocy.  (2)  Weakness, 
resulting  after  a  time  in  complete  paralysis.  (3)  A  normal,  dimin- 
ished, or  increased  state  of  the  deep  reflexes.  (4)  Increasing  blind- 
ness with  pathognomonic  changes  in  the  region  of  the  macula  lutea 
(Tay  and  Kingdon's  spot),  with  optic  neuritis.      (5)  Marasmus. 

The  history  of  all  the  cases  is  practically  the  same.  The  infant 
is  normal  at  birth.  After  from  two  to  eight  months,  it  is  found  to 
be  indifferent  to  its  surroundings.  The  mother  notices  that  the 
infant  who  has  been  bright  begins  to  lose  interest  in  the  surroundings. 
She  will  say  that  from  the  third  month  on  she  noticed  that  the  infant 


AMAUEOTIC  IDIOCY.  •  839 

no  longer  held  up  its  head  and  that  this  disability  has  gradually 
become  more  apparent.  The  head  falls  backward  when  the  infant 
is  sat  up.  The  children  do  not  notice  objects  any  more;  they  nurse 
automatically  and  start  when  there  is  any  noise  in  their  immediate 
vicinity. 

Many  of  the  infants  cry  constantly,  at  the  same  time  making 
automatic  facial  grimaces.  The  lower  extremities  are  weak  and  may 
exhibit  complete  paralysis  (diplegia).  In  other  cases,  there  may  at 
intervals  be  a  spastic  rigidity  of  the  lower  extremities,  alternating 
with  a  lax  condition.  Convulsions  are  absent  or  may  occur  occasion- 
ally. The  deep  reflexes  may  be  normal  or  diminished.  In  the 
spastic  cases  they  are  increased.  After  the  first  year  the  infants 
become  totally  blind  and  conapletely  idiotic.  They  finally  become 
marantic,  and  die  after  the  second  year  with  the  symptoms  of  ad- 
vanced infantile  atrophy.  Occasionally  there  are  nystagmus,  stra- 
bismus and  hydrocephalus.  Deafness  supervenes  in  many  cases. 
The  electrical  contractility  of  the  muscles  may  be  normal  or,  as  in 
one  of  my  cases,  diminished. 

Ocular  Changes. — The  changes  in  the  fundus  of  the  eye  described 
by  Tay  and  Kingdon  have  been  confirmed  in  the  cases  of  Sachs, 
Koller,  and  the  writer.  They  are  invariably  present  at  some  period 
of  the  disease,  but  may  only  appear  late,  as  in  the  case  of  Koller. 
Once  present,  they  fix  the  diagnosis  absolutely.  The  appearances 
consist  of  a  cherry-red  spot  on  a  diffusely  white  area  at  the  region  of 
the  macula  lutea.  Optic  neuritis  is  also  present  toward  the  close 
of  the  disease. 

Diagnosis. — Diagnosis  is  not  difficult  after  a  study  of  the  symp- 
toms. If  an  infant  is  brought  to  the  physician  with  a  history  of 
good  health  and  intelligence  up  to  a  certain  time,  after  which  weak- 
ness and  loss  of  interest  in  its  surroundings  set  in,  with  inability 
to  hold  the  head  upright,  the  fundus  of  the  eye  should  be  examined. 
If  Tay-Kingdon's  spot  is  found,  the  diagnosis  is  fixed.  I  have  lately 
seen  a  number  of  cases  in  which  the  spastic  symptoms  were  predomi- 
nant. There  were  idiocy,  increase  of  reflexes,  complete  or  total 
blindness,  and  hyperacuity.  I  have  watched  infants  with  these 
symptoms  for  a  long  time  and  failed,  even  with  expert  aid,  to  find 
Tay-Kingdon's  spot.     In  these  cases  there  was  probably  a  birth  palsy. 

The  Juvenile  Form. — The  juvenile  form  of  amaurotic  idiocy  is 
also  a  family  disease.  It  affects  several  members  of  a  family  group 
in  the  same  manner  as  the  infantile  type.  It  begins  at  the  sixth  to 
the  fourteenth  year  of  childhood.  The  onset  is  also  gradual.  The 
first  symptom  is  an  increasing  blindness,  which  in  the  course  of 
months  results  in'  a  total  blindness  due  to  an  optic  neuritis.  The 
patients  lose  interest  in  their  surroundings,  forget  what  they  have 


840  DISEASES  OF  THE  NEBVOUS  SYSTEM. 

learned  in  reading  or  writing,  take  less  and  less  care  of  themselves, 
lose  their  usual  spirits,  soil  themselves  and  finally  lose  their  povv^er 
of  speech  and  become  absolutely  imbecile  and  paralytic.  The  paral- 
ysis may  be  flaccid  or  spastic.  They  lie  for  a  long  time  moribund 
and  finally  pass  into  a  marantic  condition  and  die.  On  the  whole 
the  picture  is  much  the  same  as  the  infantile  type  with  the  exception 
that  in  the  juvenile  form  of  amaurotic  idiocy  the  cherry-red  spot  of 
Tay-Kingdon  is  not  seen  in  the  fundus  of  the  eye,  but  instead  there 
are  the  changes  due  to  a  progressive  optic  neuritis. 

Prognosis. — The  prognosis  of  both  forms  of  amaurotic  idiocy  is 
fatal,  the  infantile  before  the  second  or  third  year  and  the  juvenile 
form  after  a  year  or  more  of  illness. 

TUMORS  OF  THE  BRAIN. 

Fully  50  per  cent,  of  the  brain  tumors  in  infancy  and  childhood 
are  tuberculous;  giiomata  and  sarcomata  are  next  in  order  of  fre- 
quency. Cysts  are  secondary  to  a  hemorrhage  or  embolism.  They 
may  remain  stationary  for  a  long  period,  and  then  increase  in  size 
and  cause  symptoms.  Males  are  affected  twice  as  frequently  as 
females ;  two-thirds  of  the  cases  in  male  subjects  are  cases  of  giiomata 
and  tubercle.  Tumors  are  rare  in  the  first  six  months  of  life.  The 
largest  number  occur  in  the  first  decade. 

Location. — The  medulla  is  rarely  the  seat  of  tumor.  The  cere- 
bellum is  most  frequently  involved  (50  per  cent,  of  the  cases,  Ger- 
hardt,  Peterson).  The  pars  centrum  ovale  and  basal  ganglia  are 
the  parts  next  most  frequently  affected. 

Etiology. — ^The  role  of  traumatism  is  not  clearly  understood. 
Giiomata  are  due  to  a  proliferation  of  the  neuroglia.  Tubercle  and 
sarcomata  are  secondary  to  foci  elsewhere.  Carcinoma  is  rare.  In 
some  cases  of  that  growth  the  orbit  is  a  focus  of  infection. 

Symptoms. — Symptoms  of  pressure  and  irritation  vary  with  the 
location  of  the  tumor.  A  small  but  rapidly  growing  tumor  will 
cause  more  pronounced  symptoms  than  a  large  tumor  of  slow  growth. 
Interference  with  the  blood-supply  and  an  increase  in  the  quantity 
of  fluid  within  the  ventricles  of  the  brain  will  cause  the  symptoms 
to  vary. 

General  Symptoms.— Headache. — This  may  in  cortical  and 
meningeal  tumors  be  intense.  It  is  of  a  boring,  gnawing  character, 
and  is  referred  to  the  region  of  the  tumor.  Tumors  in  infants  may 
attain  great  size  previous  to  ossification  of  the  skull.  The  bones  of 
the  skull  are  pushed  apart  and  the  sutures  opened  up.  There  is  very 
little  pain.  Sleeplessness  and  restlessness,  emaciation,  and  cerebral 
excitement  are  marked. 


TUMOBS  OF  TEE  BBAIN.  841 

Nausea  and  Vomiting. — ISTausea  and  vomiting  are  prominent 
symptoms  and  persist  for  a  long  time.  The  vomiting  is  projectile 
and  occurs  independently  of  the  ingestion  of  food. 

Vertigo. — Vertigo  is  common  and  occurs  with  every  change  in  the 
position  of  the  head.  It  is  a  common  symptom  in  tumors  of  the  pons 
and  cerebellum. 

Convulsions. — These  may  be  localized  or  general.  They  occur 
when  the  cortex  and  motor  areas  are  invaded,  and  eventuate  in  epi- 
lepsy of  the  Jacksonian  type.  In  this  form  of  epilepsy,  the  attack 
begins  in  the  head  or  arm  corresponding  to  the  area  of  irritation,  and 
subsequently  becomes  general. 

Optic  Neuritis. — Optic  neuritis  and  optic  atrophy  are  important 
symptoms  of  intracranial  tumor,  but  are  not  always  present.  When 
tumors  are  situated  at  the  base  of  the  brain,  the  symptoms  appear 
early  and  are  due  to  pressure  on  the  chiasm.  Optic  neuritis  is  either 
double  or  more  pronounced  in  one  eye. 

Pulse  and  Respiration. — The  pulse  and  respiration  present  no 
characteristic  features.  They  show  irregularities  in  rate.  Respira- 
tion is  affected  only  toward  the  close  of  the  affection. 

Symptoms  Dependent  on  the  Location  of  the  Tumok. — Cor- 
tical tumors  in  or  near  the  motor  areas  cause  convulsive  seizures, 
which  occur  from  the  outset.  Subcortical  tumors  will  at  first  cause 
paralysis  and,  as  they  encroach  upon  the  cortex,  convulsions.  With 
invasion  of  the  cortex  there  are,  in  addition  to  convulsions  with  sub- 
quent  epilepsy,  intense  headaches.  Tubercle,  glioma,  and  gumma 
occur  near  the  surface.     Cysts  and  sarcoma  are  more  deeply  situated. 

Frontal  Lohe. — The  tumors  situated  in  the  frontal  lobe  region 
cause  stupidity  and  other  marked  changes  in  the  degree  of  intelli- 
gence. There  will  be  a  perversion  of  the  sense  of  smell,  salivation, 
and  also  the  drooling  seen  in  idiocy.  If  the  third  frontal  convolu- 
tion is  affected,  there  will  be  motor  aphasia  associated  with  agraphia 
— a  rare  condition  in  childhood.  Tumors  of  the  motor  area  will  in 
the  earlier  stages  cause  cortical  irritation,  manifested  in  convulsive 
twitchings  in  the  parts  first  paralyzed.  There  may  be  slight  sensory 
or  motor  disturbances  in  an  upper  extremity  and  an  occasional 
twitching  of  the  arm,  forearm,  or  thumb. 

Parietal  Lohe.- — The  tumors  of  the  parietal  lobe  cause  sensory 
changes  in  the  limbs  of  the  opposite  side  of  the  body  (Dana).  If 
the  white  substance  is  the  seat  of  tumor,  there  may  be  hemianopsia ; 
Wernicke's  centre  for  conjugate  movement  of  the  eyes  may  be  affected 
if  the  tumor  is  situated  in  the  inferior  part  of  the  parietal  lobe. 

Occipital  Lohe. — Tumors  of  the  occipital  lobe  cause  homonymous 
hemianopsia  with  or  without  epileptiform  convulsions,  the  latter 
being  probably  due  to  invasion  of  the  cortex. 


842 


DISEASES  OF  THE  NEBFOUS  SYSTEM. 


Temporosphenoidal  Lohe. — Tumors  of  the  temporosphenoidal 
lobe  cause  impairment  of  hearing  on  the  side  opposite  to  the  lesion 
and  sensorj  aphasia.  The  patient  is  able  to  speak,  but  cannot  under- 
stand what  is  said  or  repeat  spoken  language. 

Ganglia. — In  tumors  of  the  ganglia  there  is  involvement  of  the 
internal  capsules.  There  are  no  convulsions  and  none  of  the  choreic 
and  athetoid  movement  seen  in  cortical  tumors. 

Cims  Cerebri. — Tumors  of  the  crus  cerebri  cause  paralysis  of 
motion  and  sensation  on  the  opposite  side  of  the  body,  and  oculomotor 
paralysis,  ptosis,  and  paralysis  of  the  muscles  of  the  eyeball,  except 


Fig.  191. 

^^^^^^^ 

f 

-■  "-  ■    3imm^ 

> 

/    f  ■" 

L, 

Pons  tumor,  showing  nuclear  palsies.     Left  abducens  paralysis. 


the  external  rectus  and  superior  oblique.  There  will  be  paralysis  of 
the  sphincter  iridis  and  ciliary  muscle.  There  may  be  paralysis  of 
both  sides  of  the  body,  double  ptosis,  and  double  oculomotor  symp- 
toms. The  majority  of  cases  are  at  first  unilateral,  later  becoming 
bilateral.  Loss  of  pupillary  reflex,  nystagmus,  and  cerebellar  ataxia 
point  to  involvement  of  the  corpora  quadrigemina. 

Pons.- — Tumors  of  the  pons  cause  unilateral  or  bilateral  symp- 
toms. There  is  hemiplegia  or  double  hemiplegia  with  paralysis  of 
the  cranial  nerves.  There  is  paralysis  of  the  third,  fifth,  sixth,  sev- 
enth, and  eighth  nerves  of  the  side  of  the  lesion,  with  hemiplegia  of 
the  opposite  side.  There  may  thus  be  paralysis  of  the  external  rectus 
with  facial  palsy  and  impairment  of  hearing  on  one  side.     If  the 


PLATE  XXXVII 


Birth  Palsy,  Apoplexia  Neonatorum.    (McNutt.)     Shaded  portions 
show  the  location  of  the  hemorrhage. 


INFANTILE  CEBEBBAL  PALSY.  843 

nucleus  of  the  sixth  nerve  is  involved,  there  v^ill  be  paralysis  of  con- 
jugate movement  of  the  eyes  toward  the  side  of  the  lesion,  while  if 
it  is  not  affected  there  will  be  only  external  rectus  palsy  of  the  side 
of  the  lesion  not  affecting  conjugate  movement  of  the  other  eye. 

Medulla. — Tumors  of  the  medulla  manifest  themselves  in  bulbar 
symptoms.  There  will  be  paralysis  of  the  glossopharyngeal,  vagus, 
spinal,  accessory,  and  hypoglossal  nerves.  Thus  there  are  unilateral 
or  bilateral  paralysis  of  the  arms  or  legs,  difficult  deglutition,  and 
disturbances  of  the  respiratory  movements  and  of  cardiac  action.  In 
addition  there  will  be  spasm  of  the  sternomastoid  and  trapezius  mus- 
cles, and  paralysis  of  the  tongue,  with  atrophy,  vomiting,  polyuria, 
and  glycosuria ;  optic  neuritis  occurs  early,  and  there  is  severe  occip- 
ital headache.     Gummata  in  this  region  are  not  uncommon. 

Cerehellum. — Tumors  of  the  cerebellum,  which  are  usually  of  the 
solitary  tuberculous  form,  are  the  most  important  intracranial  growths 
in  children.  There  will  be  occipital  headache,  vomiting  early  in 
the  disease,  and  cerebellar  titubation  due  to  encroachment  upon  the 
middle  peduncle.  Vertigo  is  severe.  The  sixth,  seventh,  or  eighth 
cranial  nerves  may  be  involved.  There  may  be  bulbar  symptoms. 
Paralysis  of  the  external  rectus  is  very  common  in  these  tumors. 
Optic  neuritis  may  be  present. 

INFANTILE  CEREBRAL  PALSY. 

{Spastic  Hemiplegia ;  Diplegia;  Paraplegia.) 

Forms. — Cerebral  infantile  palsy  may  originate  m  utero,  or  a 
short  time  after  the  birth  of  the  infant.  It  is  then  called  cerebral 
diplegia,  birth  palsy  or  Little's  disease.  It  may  occur  any  time  after 
birth,  most  frequently  during  the  first  three  years  of  life.  The  palsy 
then  has  an  acute  onset  and  takes  the  hemiplegic  form  and  is  called 
hemiplegic  infantile  cerebral  palsy.  These  two  forms  of  cerebral 
palsy  have  much  in  common  both  as  to  pathology  and  symptomatology. 

Cerebral  Diplegia,  Little's  Disease. — This  affection,  first  brought 
to  the  notice  of  the  profession  by  Little,  was  also  studied  by  MclSTutt. 
To  the  latter  we  owe  the  demonstration  of  the  cause  of  the  disease. 
Lender  the  title  Apoplexia  Neonatorum  she  demonstrated  that  in  easy 
as  well  as  j)rolonged  labor  and  instrumental  deliveries  hemorrhage 
on  the  surface  of  the  brain  was  the  first  step  in  the  clinical  and  patho- 
logical history  of  these  cases  (Plate  XXXVII.) .  Cerebral  diplegia 
is  a  form  of  bilateral  paralysis  dating  from  birth  or  noticed  soon  after 
birth  or  as  the  result  of  some  infectious  disease  as  late  as  the  sixth 
month  after  birth  (Henoch) ,  or  even  the  third  year  of  life  (Starr). 

Etiology. — The  etiology  is  divided  into  first,  those  cases  in  which 
the  causes  are  traced  to  intra-uterine  life  and  are  connected  with 


844  DISEASES  OF  TEE  NEEVOUS  SYSTEM. 

disturbances  in  utero  due  to  traumatism  to  the  mother  during  preg- 
nancy, illness  or  psychical  disturbances  of  the  mother,  and  syphilis. 

Second  are  the  causes  which  act  on  the  child  during  labor,  difficult 
parturition,  abnormal  position  of  the  child,  asphyxia,  either  through 
prolonged  labor  or  abnormal  position  of  the  cord,  or  premature  de- 
tachment of  the  placenta,  and  prematurity  of  the  infant  or  labor. 

Third,  there  are  the  etiological  factors  acting  on  the  infant  after 
birth,  such  as  the  infectious  diseases.  Such  cases  have  been  observed 
by  Henoch  in  an  infant  who  six  months  after  birth  developed  diplegia 
after  measles. 

Symptoms. — MclS'utt  described  the  symptoms  referable  to  the  cere- 
bral hemorrhage  in  cases  of  diplegia.  They  consist  of  disturbances  of 
respiration  more  or  less  marked,  partial  or  complete  loss  of  conscious- 
ness and  convulsions.  The  latter  may  be  general  or  involve  half  of 
the  body.  Many  of  such  infants  die  soon  after  birth.  If  they  live, 
they  show  signs  of  asphyxia  neonatorum.  In  such  cases  even  after  a 
normal  delivery,  the  infant  breathes  irregularly,  or  ceases  to  breathe, 
cries  feebly  and  then  lapses  into  a  quiescent  state  with  shallow  and 
irregular  breathing.  It  may  be  cyanosed  and  in  this  state  may  have 
several  convulsions.  Other  cases  are  born  apparently  well  but  after 
twenty-four  hours  convulsions  and  disturbed  respirations  appear.  If 
these  infants  live,  the  subsequent  clinical  history  is  as  follows : 

Diplegia. — In  many  cases  the  diplegia  consists  in  a  paralysis  of 
both  arms  and  legs  or  of  the  legs  alone  and  is  noticed  soon  after  birth. 
The  parents  observe  that  voluntary  motion  is  interfered  with,  that  the 
infant  is  alternately  rigid  and  lax,  is  not  intelligent  and  does  not 
nurse  as  ordinary  infants  do.  There  is  hyperacusis ;  the  children 
start  at  the  least  sound  and  cry  as  if  in  fright.  The  reflexes  are 
much  increased,  the  trunk  and  extremities  are  rigid.  In  some  cases 
the  back  is  rigid  and  the  children  are  unable  to  sit  upright.  There 
is  difficulty  in  nursing  and  some  must  be  fed  by  hand.  As  the  child 
grows,  it  is  seen  to.be  mentally  deficient,  notices  objects  in  a  vague 
sort  of  way,  cannot  talk,  cannot  sit  on  account  of  the  rigidity,  and 
cannot  stand.  If  aided  these  children  may  stand,  but  the  extrem- 
ities take  a  spastic  position.  The  toes  are  applied  to  the  ground 
and  there  are  crossing  of  the  legs  and  equino  varus.  The  heels  do 
not  touch  the  ground  and  the  children  cannot  balance  themselves. 
Some  may  be  able  to  walk,  but  only  stiffly,  aiding  themselves  with 
the  hands ;  others  may  walk  with  the  aid  of  support,  such  as  a  cane 
or  crutch.  These  are  favorable,  as  many  of  the  children  are  bed- 
ridden. In  such  cases  the  arms  are  flexed  and  spastic,  as  are  also 
the  lower  extremities.  There  are  constant  athetoid  movements,  com- 
bined with  chorea,  both  of  facial  muscles  and  extremities,  and  finally 
epilepsy  is  often  developed,  so  that  the  difference  in  symptomatology 
between  these  cases  and  those  of  hemiplegia  is  only  one  of  degree. 


INFANTILE  CEBEBEAL  PALSY.  845 

The  feeble-mindedness  of  such  children  and  their  utter  helpless- 
ness is  touching.  They  can  be  taught  only  the  simplest  things  and 
until  late  in  childhood  they  are  a  burden  to  themselves  and  others. 
There  is  no  marked  improvement  and  many  become  easy  prey  to 
intercurrent  affections.  Optic  atrophy,  blindness,  nystagmus,  stra- 
bismus, deafness,  are  among  the  other  symptoms  noted  in  many  cases. 
In  some  there  are  symptoms  of  bulbar  involvement,  such  as  difficulty 
in  deglutition  and  motor  disturbances  of  speech. 

Convulsions  and  epilepsy  develop  later  on  and  in  many  cases  lead 
to  complete  idiocy  if  such  v^as  not  present  at  birth. 

Hemipleg-ic  Infantile  Cerebral  Palsy  (Spastic  Hemiplegia). — 
Occurrence. — According  to  Gowers  the  disease  is  more  frequent  in 
females,  but  there  is  no  predisposition  as  to  sex.  It  is  most  frequent, 
according  to  Osier,  Wallenberg,  Gaudard,  Lovett,  Sachs,  and  Peter- 
sen, in  children  from  a  few  months  of  age  to  the  third  year  of  life, 
when  it  becomes  infrequent  up  to  the  tenth  year.  All  the  above 
writers  report  cases  occurring  in  utero  or  congenital  (intra-uterine 
and  during  parturition). 

Etiology. — The  etiology  of  these  cases  is  still  a  matter  of  discus- 
sion. When  Striimpel  proposed  the  theory  of  an  encephalitis  similar 
to  that  occurring  in  infantile  poliomyelitis,  it  was  for  a  short  time 
accepted.  Clinically  this  theory  was  founded  on  certain  similarities 
between  the  spinal  and  cerebral  affections.  It  is  found  that  many 
of  the  cases  follow  the  acute  infectious  diseases,  especially  measles 
and  scarlet  fever  (Gowers).  Cerebral  palsy  may  follow  typhoid 
fever,  pertussis,  pneumonia,  amygdalitis,  cerebrospinal  meningitis, 
gastro-enteritis,  and  traumatism  to  the  skull.  Infection  or  the  pres- 
ence of  infectious  disease  cannot  alone  explain  all  the  cases.  Another 
view  is  that  the  convulsion  at  the  outset  of  the  disease  causes  the 
bursting  of  a  vessel  weakened  by  some  form  of  degeneration  (Osier). 

Symptoms. — General  Picture. — The  disease  occurs  from  the  age 
of  a  few  months  to  three  years.  There  are  at  first  in  the  acute  stage, 
fever,  convulsions,  vomiting,  which  may  extend  over  a  period  of  a 
few  days  or  weeks.  During  this  stage  or  later  the  paralysis  which 
involves  the  face,  arm  and  lower  extremity  becomes  evident.  The 
paralysis,  as  first  flaccid,  soon  becomes  spastic  with  increase  of  reflexes 
and  contractures.  Disturbances  of  speech  and  aphasia  are  common, 
but  for  the  most  part  temporary.  In  rare  cases  there  occur  ocular 
palsies.  The  hemiplegia  may  disappear  to  recur  or  it  may,  as  in 
most  cases,  remain  permanent.  The  improvement  in  the  paralysis 
occurs  mostly  in  the  lower  extremity  and  is  less  evident  in  the  arm 
and  forearm.  With  the  improvement  of  the  paralysis  there  appears 
the  so-called  post-hemiplegic  chorea.  The  paralysis  remains  spastic. 
There  are  more  or  less  marked  disturbances  of  the  intelligence.     Later 


846  DISEASES  OF  THE  KEETOUS  SYSTEM. 

in  life,  varying  in  different  cases,  epilepsy,  at  first  limited  to  one 
side  and  then  general  and  severe,  makes  its  appearance  (Fig.  192). 

Paralysis. — The  paralysis  involves  both  sides  with  about  equal 
frequency.  It  is  of  the  spastic  type.  The  facial  muscles  are  in- 
volved to  a  mild  degree;  more  markedly  paralyzed  are  the  muscles 
of  the  upper  extremity,  less  those  of  the  arm  and  least  or  not  involved 
at  all  are  the  gluteal  and  abdominal  group.  The  facial  muscle  is 
frequently  involved  in  the  hemiplegic  form;  fully  in  half  the  cases 
(Konig).  It  is  not  very  marked,  certainly  not  as  much  as  the  paral- 
ysis of  the  extremities.     In  exceptional  cases  the  reverse  is  true. 

Hemiplegia.  —  The  hemiplegia  may  present  mixed  forms  of 
paralysis.  The  arm  and  forearm  are  more  affected  than  the  lower 
extremity.  There  may  be  apparent  monoplegia  of  the  upper  extrem- 
ity with  facial  paralysis  on  the  same  side  or  athetosis  or  chorea  of 
the  lower  extremity.  There  may  be  diplegia  of  the  lower  extremities 
with  increased  reflexes  on  both  sides,  combined  with  a  hemiplegia,  or. 
as  Lovett  points  out,  a  hemiplegia  may  result  in  subsequent  spastic 
paraplegia. 

Contractures,  Befexes,  Position,  and  Gait. — The  arm  is  closely 
applied  to  the  trunk,  the  forearm  is  held  in  semi-pronation  and  flexed 
at  a  right  angle  against  the  arm.  The  elbow  is  carried  close  to  the 
body.  The  hand  is  bent  to  the  ulnar  side  and  the  fingers  are  flexed 
more  or  less  into  the  hollow  of  the  hand,  covering  the  thumb.  The 
lower  extremity  is  slightly  rotated  inwards  and  the  leg  flexed  slightly 
on  the  thigh  with  plantar  flexion  of  the  foot.  The  toe  is  pointed 
inward,  giving  the  equinovarus  position  to  the  foot.  In  the  majority 
of  cases  the  great  toe  is  over-extended  at  right  angles  to  the  meta- 
tarsus (Gaudard).  The  contractures  which  are  thus  pictured  may 
appear  in  utero,  or  immediately  after  the  onset  of  the  paralysis,  or, 
what  is  common,  the  paralysis  is  first  flaccid  and  then  becomes  spastic 
with  contractures,  or  the  contractures  at  first  may  be  evanescent  and 
not  reappear,  or  contractures  may  be  absent,  especially  in  congenital 
cases.  Contracture,  if  once  present,  fixes  the  extremity  so  that  it 
cannot  be  straightened,  even  under  narcosis.  Sometimes  at  the  height 
of  the  paralysis  the  contracture  may  relax  or  relax  in  one  extremity 
and  persist  in  another  or  athetosis  may  be  present  in  the  hand,  while 
contracture  exists  in  the  arm  and  forearm,  or  chorea  may  be  present 
in  one  extremity  and  contractnre  in  another  (Fig.  193). 

The  patellar  reflex  is  increased  as  a  rule  but  it  may  be  absent  in 
the  presence  of  chorea  or  much  diminished.  In  severe  spastic  paral- 
ysis there  is  bilateral  increase  of  reflex. 

The  gait  is  dependent  chiefly  on  the  conditions  present.  In  sim- 
ple hemiplegia  the  gait  is  that  seen  in  hemiplegia  of  the  adult.  If 
the  foot  is  badly  affected  in  equinovarus  the  children  walk  practically 


INFANTILE  CEREBRAL  PALSY. 


847 


on  the  toes  of  the  affected  limb.     If  the  opposite  side  is  spastic,  the 
gait  is  that  of  ataxia  and  spastic  paraplegia. 

Ocular  Palsies. — The  ocular  palsies  which  may  be  present  in 
infantile  cerebral  palsj  include  oculomotor  paralysis ;  ptosis,  on  the 
side  of  the  paralysis,  and  temporary  abducens  paralysis  (Freud  and 


Fig.  192. 


Fig.  193. 


Cerebral   palsy,    left   side   hemipleglc, 
dating  from    early    infancy. 


Cerebral  Daisy,  left  side 
hemipleglc,  dating  from  later 
childhood. 


Eie).  Homonymous  lateral  hemianopsia  has  been  described  by 
Freud  in  1889.  It  is  rare  but  it  occurs  as  Sachs  has  found  it  in  8 
cases.     Freud  regards  the  hemianopsia  as  of  cortical  origin. 

Sensibility. — Sensibility  is  somewhat  though  not  markedly  dis- 
turbed in  children.     There  is  slightly  marked  hemiansesthesia.     The 


848  DISEASES  OF  THE  NEBVOUS  SYSTEM. 

most  irksome  are  pains  in  the  extremities  traceable  to  the  muscle 
conditions.  The  shoulder  and  elbow  especially  may  be  the  seat  of 
these  pains. 

Aphasia. — ^Aphasia  may  be  present  either  as  a  true  aphasia  or 
there  may  not  be  a  true  aphasia,  but  the  children  are  slow  to  learn 
spoken  language.  Aphasia,  however,  is  not  as  a  rule  a  permanent 
symptom.  Aphasia  may  exist  in  either  right-  or  left-sided  hemi- 
plegia. The  aphasia  is  therefore  an  ataxic  motor  aphasia  and  in 
lesions  of  the  speech-centre  on  the  left  side,  the  right  hemisphere  in 
children  may  act  in  a  compensatory  manner  and  an  improvement  in 
the  aphasia  results. 

Post-hemiplegic  Disturbances. — Post-hemiplegic  disturbances  of 
motion  take  place  in  the  paralyzed  members  and  are  of  three  classes 
in  the  presence  of  voluntary  intended  acts.  The  voluntary  motion 
may  be  attended  by  spastic  contraction  either  in  the  presence  or 
absence  of  contracture  of  the  extremities.  There  is  ataxia,  that  is, 
after  the  impulse  is  conveyed  to  a  group  of  muscles,  there  is  hesita- 
tion before  the  intended  act  is  accomplished.  Finally  we  have  in  the 
paralyzed  members  so-called  post-hemiplegic  chorea  as  in  cases  of 
ordinary  chorea  on  attempts  to  use  the  paralyzed  muscles. 

"Chorea." — After  the  completion  of  the  stage  of  complete  paral- 
ysis, we  have  in  almost  all  the  cases  in  which  spastic  ataxia  accom- 
panies voluntary  motion  a  further  development  of  spontaneous  move- 
ments in  the  form  of  "  chorea  "  independent  of  the  will.  On  the 
appearance  of  chorea  in  the  paralyzed  members,  the  contractures  dis- 
appear, but  motion  and  voluntary  use  of  the  limb  is  more  than  ever 
hampered  by  the  choreatic  motion.  Chorea  may  affect  one  or  both 
paralyzed  members,  and  may  appear  at  the  time  of  the  contracture 
or  later  on. 

Athetosis. — Added  to  the  chorea  is  athetosis.  This  consists  in 
slow,  involuntary  movements  of  the  paralyzed  part,  producing  flexion 
and  extension  of  the  fingers  and  hand,  of  the  elbow  and  shoulder,  and 
more  rarely  of  the  foot  and  muscles  of  the  face.  It  is  increased  by 
voluntary  motion  of  the  paralyzed  or  healthy  jDart,  or  emotional 
excitement.  This  athetosis  was  first  described  by  Hammond,  and 
is  now  recognized  to  be  due  to  a  lesion  of  the  brain  cortex.  It  may 
appear  early  or  late  in  the  disease.  It  is  a  frequent  symptom. 
Athetosis  differs  from  the  chorea  in  that  it  is  a  rhythmic  motion  in 
contrast  to  the  changeable  sudden  motion  of  chorea. 

Trophic  Disturbances. — Trophic  disturbances  occur  in  infantile 
cerebral  palsy  and  affect  the  soft  parts  and  the  bones  of  the  skull 
and  extremities  and  joints.  There  are  thickening  and  irregularities 
of  the  bones  of  the  skull.  The  muscles  of  the  face  and  extremities 
are  slightly  atrophic.     The  electrical  reactions  of  muscle  in  the  par- 


INFANTILE  CEEEBBAL  PALSY.  849 

alyzed  members  show  no  change  except  in  cases  of  very  long  stand- 
ing, where  there  is  a  change  in  the  muscular  reactions.  There  is 
also  a  retardation  in  growth  of  bone  and  muscle. 

Epilepsy. — Epilepsy  appears  in  most  cases  of  infantile  hemi- 
plegia as  a  closing  complication.  It  may  appear  after  the  lapse  of 
several  years  or  may  in  unusual  cases  come  on  after  the  initial  con- 
vulsions. As  a  rule  the  more  recent  the  case  the  less  likely  there  is 
to  be  epilepsy,  so  that  the  first  two  years  of  life  are  free  from  it.  The 
frequency  of  this  complication  varies  with  the  cases  studied.  Thus 
Gowers  gives  the  frequency  as  66  per  cent,  in  his  cases,  while  Gaudard 
found  it  in  13  per  cent.,  and  Sachs  in  50  per  cent. 

At  first  the  epileptic  seizures  are  not  as  outspoken  as  in  true 
epilepsy.  The  aura  is  more  distinct  and  gives  warning  in  time,  the 
initial  cry  is  wanting,  the  biting  of  the  tongue  less  frequent  and  coma 
and  delirium  do  not  follow  the  attack.  While  this  is  so  at  first,  the 
subsequent  course  is  such  that  ultimately  there  is  no  difference  be- 
tween these  epileptic  seizures  and  those  of  true  epilepsy.  The  condi- 
tion of  the  mind  suffers  in  all  cases  of  hemiplegia,  from  mild  states 
of  weakened  intelligence  to  total  idiocy.  The  epileptic  seizures  con- 
tribute still  further  to  intensify  the  injury  to  the  psychic  sense. 

Course.- — It  will  be  seen  from  the  above  that  the  cases  of  infantile 
cerebral  paralysis  or  hemiplegia  have  a  certain  course :  the  prodromal 
stage,  the  paralysis  with  contracture,  the  chorea,  and  finally  the 
epilepsy.  All  cases  do  not  develop  chorea  and  epilepsy,  nor  does  the 
paralysis  show  an  equal  intensity  in  all  cases.  Some  show  an  evanes- 
cence of  paralysis ;  in  others  the  paralysis  is  very  mild,  without 
chorea  or  epilepsy,  and  lastly  cases  occur  in  which  in  the  stage  of 
epilepsy  the  paralysis  disappears,  so  as  to  mislead  into  a  diagnosis  of 
primary  epilepsy.  In  other  instances  the  epileptic  seizures  when 
they  appear  and  as  they  do  dominate  the  clinical  picture  may  miti- 
gate and  disappear  after  short  or  long  intervals. 

Morbid  Anatomy. — Prenatal  Cases. — There  is  porencephaly.  Half 
a  hemisphere,  an  entire  hemisphere,  or  both  hemispheres  may  be  im- 
perfectly developed.  There  are  also  certain  defects  in  the  cerebral 
hemisphere  to  which  is  applied  the  term  "  Agenesis  Corticalis." 
That  is  to  say,  there  is  imperfect  development  of  the  cortical  gray 
cells,  particularly  those  of  the  pyramidal  type.  The  agenesis  may 
extend  throughout  all  parts  of  the  hemispheres. 

Birth  Palsies. — The  principal  lesion  is  meningeal  hemorrhage 
(MclSTutt).  This  may  occur  in  areas  over  the  cortex,  or  at  the  base 
of  the  brain.  There  may  be  a  diffuse  hemorrhage  over  the  whole 
cortex  of  one  hemisphere.  The  extravasation  is,  as  a  rule,  most  pro- 
fuse over  the  motor  area. 

54 


850  DISEASES  OF  TEE  NEBVOUS  SYSTEM. 

Acute  Palsies. — In  these  there  are  found  embolism  and  throm- 
bosis, or  hemorrhage,  the  latter  occurring  mostly  at  an  advanced  age. 
As  a  result  there  may  be  atrophy  of  the  cortex,  sclerosis  or  cyst  forma- 
tions. Cysts  are  sometimes  found  later  in  life,  there  having  been  no 
previous  symptoms  (Gowers).  They  undoubtedly  originate  in  in- 
fancy. Some  authors  (Gowers)  state  that  embolism,  others  that 
hemorrhage,  is  the  pathological  condition  most  frequently  found  in 
cerebral  palsies  of  acute  origin.  The  cause  of  hemorrhage  in  these 
cases  is  still  a  matter  of  speculation.  There  is  certainly  a  change  in 
the  bloodvessels,  but  whether  it  is  the  fatty  change  seen  in  the  blood- 
vessels in  infancy  and  first  pointed  out  by  von  Recklinghausen,  is  a 
question.  It  may  be  that,  given  a  vulnerable  bloodvessel,  heart  dis- 
ease or  any  infectious  disease  will  j^redispose  to  hemorrhage.  Cysts 
are  likely  to  be  found  in  cases  in  which  there  is  idiocy. 

Diagnosis. — Intra-uterine  and  birth  palsies  give  a  distinct  history 
of  early  development.  If  a  palsy  has  developed  a  few  months  after 
a  normal  labor,  it  is  to  be  classed  as  possibly  intra-uterine.  Both 
prenatal  and  birth  palsies  are  likely  to  be  diplegic  or  paraplegic.  As 
a  rule  there  is  mental  deficiency.  Paralysis  may  be  complete,  or,  as 
in  one  of  my  cases,  scarcely  noticeable.  Double  athetosis  is  indica- 
tive of  double  hemiplegia,  and  may  even  take  the  place  of  paralysis. 
Choreiform  movements  are  frequently  mistaken  for  chorea.  They 
are  unilateral  and  combined  with  exaggerated  reflexes  and  partial, 
slight,  or  marked  paralysis.  Aphasia  of  cerebral  palsies  is  motor 
rather  than  sensory.  Its  presence  precludes  the  possibility  of  the 
palsy's  being  of  prenatal  or  of  birth  origin. 

The  cerebral  palsies  are  differentiated  from  the  infantile  forms 
of  paralysis  by  the  presence  of  spasticity,  contractures,  rigidity,  in- 
crease of  deep  reflexes,  and  occasionally  by  the  presence  of  athetosis 
and  choreiform  movements  and  epilepsy.  In  recent  cases  the  absence 
of  atrophy  will  also  aid  in  diagnosis. 

Prognosis. — So  far  as  prenatal  and  birth  forms  of  palsy  are  con- 
cerned, no  definite  prediction  in  regard  to  the  outcome  can  at  first 
be  made.  Many  of  the  cases  of  birth  palsy  die  at  the  outset.  Some 
escape  with  very  slight  paralysis.  Others  develop  convulsions  with 
subsequent  epilepsy  and  idiocy.  Contractures,  diplegia,  and  double 
hemiplegia  with  spastic  symptoms  may  develop.  The  acute  cerebral 
forms  may  improve  to  such  an  extentthat  only  slight  paralysis,  chorei- 
form movements,  or  athetosis  remain.  In  other  cases  improvement 
is  followed  by  a  return  of  the  symptoms,  with  convulsions  and  epi- 
lepsy. It  is  estimated  that  fully  45  per  cent,  of  the  cerebral  palsies 
develop  epilepsy,  while  the  diplegic  forms  are  less  likely  to  do  so. 
One  convulsion  is  apt  to  be  followed  by  others,  and  these  in  time  by 
epilepsy  and  mental  deficiencies. 


FACIAL  PALSY.  851 

Treatment. — The  treatment  of  cerebral  palsjis  ultra-conservative. 
Cases  of  birth  palsy  have  difficnltj  in  deglutition.  Aid  in  keeping 
up  the  nutrition  of  the  patient  may  be  given  by  spoon-feeding  or 
feeding  with  stomach-tubes  (gavage).  If  there  are  convulsions,  bro- 
mides in  moderate  doses  are  administered.  The  infant  should  be 
kept  perfectly  quiet.  In  the  acute  cerebral  cases,  if  hemorrhage  is 
suspected,  rest  and  the  application  of  an  ice-bag  to  the  head  are  indi- 
cated. Subsequent  convulsions  are  treated  vs^ith  bromides.  The 
bowels  are  kept  open  with  calomel.  In  cases  in  which  there  is  slightly 
marked  paralysis,  massage  and  the  various  forms  of  hydrotherapy 
are  of  great  utility.  The  faradic  current  has  much  the  same  effect 
as  massage.  If  contractures  and  choreiform  movements  supervene, 
the  various  orthopsedic  appliances  are  of  great  practical  utility. 
Where  indicated,  they  should  be  used  in  connection  with  judicious 
tenotomy.  Surgical  interference  has  been  practised  in  forms  of  epi- 
lepsy which  simulate  the  Jacksonian  type.  The  results  are  disas- 
trous in  young  children,  nor  is  permanent  relief  to  be  expected  in 
older  ones. 

FACIAL  PALSY. 

{Bell's  Paralysis.) 

Paralysis  of  the  facial  nerve  is  quite  common  in  infancy  and 
childhood.  As  in  the  adult,  the  distribution  and  etiology  of  the 
paralysis  vary. 

The  facial  paralysis  observed  in  infants  who  have  been  delivered 
with  forceps  is  a  pressure  paralysis.  It  may  affect  the  upper  or 
lower  branches  of  distribution.  The  prognosis  of  this  form  of  paral- 
ysis is,  as  a  rule,  very  good.  Recovery  takes  place  after  a  few  weeks. 
Some  cases  do  not  thus  recover;  there  should  therefore  be  some  con- 
servatism in  prognosis.  Congenital  facial  palsy  may  occur  in  the 
absence  of  any  history  of  traumatism  or  pressure.  Henoch  records 
such  a  case  in  a  boy  of  ten  years.  There  was  deafness  on  the  side  of 
the  paralysis,  but  no  history  of  disease  of  the  ear. 

The  so-called  rheumatic  form  of  facial  paralysis  occurs  in  infants 
and  children,  but  rarely  does  so  before  the  third  year,  and  most  com- 
monly between  the  sixth  and  fifteenth  years..  The  symptoms  are  the 
same  as  in  later  life  (Figs.  194  and  195). 

Of  greatest  interest  to  the  practitioner  are  the  facial  palsies 
which  occur  in  infants  and  children  as  a  result  of  ear  disease  or  of 
inflammatory  disease  of  the  mastoid  process.  In  infants  a  few 
months  old,  I  have  seen  facial  palsy  due  to  otitis  in  one  ear  (Fig. 
196).  Henoch  has  seen  cases  in  infants  from  three  to  five  months 
of  age.     The  facial  nerve  is  affected  as"  it  passes  through  the  Fallo- 


852 


DISEASES  OF  THE  NEEFOUS  SYSTEM. 


pian  canal.     Caries  of  the  bone,  pus,  or  swelling  in  the  vicinity  of 
the  canal,  will  cause  this  form  of  paralysis.     It  is  therefore  a  species 


Fig.  194. 


Facial  paralysis,  left  side,  rheumatic  form.     Girl,  eight  years  of  age. 
Fig.  195. 


Facial  paralysis,  rheumatic  form,  showing  inability  to  close  the  eye.     Girl,  eight 

years  of  age. 

of  pressure  paralysis.     There  may  he  no  distinct  collection  of  pus  in 
the  mastoid  cells,  but,  when  opened  up,  the  mastoid  is  found  to  be 


FACIAL  PALSY. 


06 


filled  with  granulations.  Temperature,  tenderness,  and  redness  over 
the  mastoid  should  arouse  suspicion. 

Bokai  reports  a  case  of  retropharyngeal  abscess  in  which  the 
facial  palsy  was  caused  by  pressure  on  the  nerve  as  it  emerged  from 
the  stylo-mastoid  foramen. 

Another  form  of  facial  palsy  is  that  seen  in  basilar  disease  of  the 
brain.  The  facial  palsy  seen  in  tuberculous  meningitis  and  some- 
times in  the  non-tuberculous  variety  is  of  great  diagnostic  import. 
This  paralysis  is  not  always  marked ;  it  is  often  a  very  slight  paresis 
with  flattening  of  the  facial  muscles  on  one  side  and  accompanied  by 
slight  widening  of  the  palpebral  fissure  on  the  same  side.  In  con- 
nection with  this  symptom,  a  dilatation  of  one  -pwpil  or  slight  stra- 

FiG.  196. 


Facial  palsy  complicating  otitis.     Infant,  seven  months  of  age. 

bismus  is  exceedingly  significant  of  basilar  affection.  In  other 
words,  in  the  forms  of  meningitic  facial  palsy,  the  physician  should 
be  on  the  alert  for  changes  in  the  contour  of  the  face,  since  in  many 
of  these  cases  the  patient  is  conscious  only  at  intervals.  In  many 
cases,  restlessness  on  the  part  of  the  patient  will  cause  the  slight 
flatness  of  the  face  or  widening  of  the  ^^alpebral  fissure  to  disappear. 
The  patient  should  be  watched  unawares  or  when  at  perfect  rest. 
The  facial  palsies  with  cerebellar  tumors  and  tumors  of  the  pons  have 
been  referred  to  in  the  section  on  Tumors. 

Operative  facial  palsy  in  infants  and  children  is  likely  to  occur 
after  the  radical  operation  on  the  mastoid,  if  the  operator  is  not  a 
thorough  anatomist.  I  have  felt  that  this  accident  could  be  avoided. 
After  an  operation  on  the  mastoid  I  have  seen  mild  facial  palsy, 
consisting  of  a  very  slight  lagophthalm.os  with  slight  flattening  of 
the  facial  muscles,  which  disappeared  within  twenty-four  hours.     It 


854  DISEASES  OF  THE  NEEVOUS  SYSTEM. 

was  possibly  due  to  j)ressiu-e  on  the  nerve  during  the  operation. 
Facial  palsy  following  a  mastoid  operation  is,  as  a  rule,  due  to  actual 
traumatism  to  the  nerve,  and  to  its  partial  or  total  destruction.  The 
paralysis  in  such  cases  is  permanent.  Finally  there  is  a  facial  palsy 
described  in  the  article  upon  poliomyelitis. 

Treatment.— The  treatment  of  facial  palsy  in  infants  and  children 
is  determined  by  the  origin  of  the  palsy,  and  is  essentially  the  same 
as  in  the  adult. 

MULTIPLE  NEURITIS. 

This  is  an  affection  in  which  several  or  most  of  the  peripheral 
nerves  undergo  degeneration  of  an  acute  type.  The  nerves  affected 
are,  as  a  rule,  symmetrically  distributed. 

Etiology. — The  disease  may  be  caused  by  the  poisonous  action  of 
drugs,  such  as  lead,  arsenic,  and  alcohol.  It  follows  the  infectious 
diseases- — measles,  diphtheria,  typhoid  fever,  influenza,  and  malaria. 
In  such  cases  the  degeneration  is  due  to  the  action  of  bacterial 
toxins  on  the  peripheral  nerves.  Cold  is  said  to  favor  the  onset 
of  the  disease.  In  many  cases  it  is  impossible  to  fix  upon  any  defi- 
nite cause. 

Frequency. — If  we  excc]:)t  diphtheritic  paralysis,  affections  of  the 
peripheral  nerves  are  much  less  common  in  childhood  than  in  later 
life.  It  is  extremely  rare  in  early  infancy,  though  I  have  seen  mul- 
tiple neuritis  follow  measles,  in  which  the  nerves  of  the  face,  the 
eyes,  the  soft  palate,  the  extremities,  and  trunk  were  involved  in  a 
child  of  fourteen  months  of  age.  When  it  does  occur  in  childhood, 
there  is  a  strong  hereditary  predisposition,  or  the  morbific  influence 
in  the  case  has  especial  predilection  for  the  peripheral  nerves. 

Morbid  Anatomy. — There  is  an  early  stage  during  which  there  are 
hypera?mia  and  swelling  of  the  sheaths  of  the  nerves,  which  may  be 
the  seat  of  minute  hemorrhages.  The  nuclei  of  the  sheaths  are 
enlarged.  There  is  an  increase  of  connective-tissue  cells  between  the 
nerve-sheaths,  and  also  of  round  and  spindle-shaped  cells  between 
the  nerve-fibers.  The  changes  in  the  nerve-fibres  are  characteristic 
of  nerve  degeneration.  The  musclos  may  l)e  the  seat  of  parenchy- 
matous degeneration.  The  striation  may  become  indistinct.  In 
some  cases  there  are  also  interstitial  changes. 

Symptoms. — The  syinjjfonis  of  multiple  neuritis  in  children  are 
very  characteristic.  After  an  infectious  disease,  the  child  no  longer 
walks  with  a  steady  gait,  bnt  may  stumble  and  fall.  After  a  time 
it  is  noticed  that  the  ])ati('n1  docs  not  care  to  stand,  and  the  mother  is 
unable  to  persuade  it  to  do  so.  The  child  cries  when  put  on  its  feet, 
which  refnse  to  supjiort  il.  I'lici-c  scorns  to  be  pain  connected  with 
an  attempt  to  stand,  jiiid  also  (ui  li;in<lliii!i-  iind  ])ressing  the  muscles. 


MULTIPLE  NEUBITIS.  ■  855 

Paralysis. — After  a  time  the  child  does  not  sit  upright,  but  falls 
back  or  toward  one  side  when  put  in  the  sitting  posture.  It  finally 
becomes  completely  paralyzed.  The  paralysis  is  progressive  and 
symmetrical.  The  child  does  not  use  the  hands.  The  feet  drop 
forward  (foot-drop)  and  there  is  a  very  characteristic  wrist-drop. 
The  child  lies  helpless  in  the  crib,  unable  to  move.  Some  of  these 
patients  cry  constantly  as  if  in  pain.  During  this  time  there  is  good 
nutrition  and  the  appetite  is  good.  The  muscles  of  the  trunk  are 
frequently  affected  as  well  as  those  of  the  extremities.  In  these  cases 
there  is  a  species  of  paralytic  lordosis  when  the  child  stands  or  sits 
upright.  In  a  few  cases  the  muscles  of  the  eye  are  affected,  and  in 
fatal  cases  those  of  the  diaphragm. 

The  facial  and  hypoglossal  nerves  are  rarely  the  seat  of  the  dis- 
ease. The  musculospiral  and  peroneal  nerves  seem,  as  in  polio- 
myelitis, to  be  affected.  The  reflexes  are  diminished  and  finally 
disappear.  The  dorsum  of  the  feet  and  hands  is  slightly  affected 
with  cedema. 

Sensory  Disturbances. — In  spite  of  statements  to  the  contrary,  it 
is  very  difficult  in  children  and  infants  to  elicit  exact  data  as  to  the 
pain  or  sensory  changes  and  their  distribution.  I  have  found  evi- 
dences of  pain  on  handling  the  children  or  attempting  to  make  them 
stand  or  sit.  The  patients  are  restless  at  night,  and  cry  most  of  the 
time,  and  it  must  therefore  be  inferred  that  they  have  pain. 

Course,- — The  majority  of  the  cases  make  a  complete  or  almost 
complete  recovery.  In  a  case  which  I  watched  very  closely  the 
reflexes  were  slow  to  return,  although  the  child  began  to  sit  upright, 
then  to  stand,  and  finally  to  walk.  The  gait  in  walking  was  very 
peculiar.  It  was  a  sort  of  waddle,  resembling  that  exhibited  in  con- 
genital luxation  of  the  hips.  The  boy,  three  years  of  age,  finally 
made  a  complete  recovery. 

As  a  rule,  the  symptoms  increase  in  severity  for  from  four  to  six 
weeks ;  they  then  retrograde  and  improvement  sets  in.  In  some  cases 
the  development  of  symptoms  is  rapid,  the  diaphragm  becomes 
affected,  and  the  children  die  of  bronchopneumonia.  If  the  vagTis 
is  affected,  death  occurs  through  cardiac  failure.  Diphtheritic  cases 
are  apt  to  be  progressive  and  fatal. 

Diagnosis. — If  the  clinical  picture  is  studied,  the  diagnosis  is 
not  difficult.  The  complete  and  absolute  paralysis  is,  in  its  mode  of 
onset  and  its  symmetrical  distribution  with  anatomical  impairment 
of  sensation  of  all  kinds,  so  peculiar  that  it  cannot  be  confounded 
with  poliomyelitis.  In  the  cases  which  I  have  seen  the  muscular 
atrophy  was  also  less  marked  than  in  the  latter  disease.  The  very 
characteristic  feature  of  the  paralysis  is-  its  flaccidity.  If  the  child 
is  made  to  sit  upright,  the  glutei  muscles  flare,  as  it  were,  outside 


856 


DISEASES  OF  THE  NEEVOUS  SYSTEM. 


the  body-line  and  do  not  retain  the  tonicity  of  the  normal  muscle. 
There  is  nevertheless  not  much  atrophy  of  the  glutei.  Landry's 
paralysis  is  so  rare  in  infancy  and  childhood  that  it  need  not  be  con- 
sidered in  detail. 

The  pain  in  these  cases  is  always  marked,  even  in  young  children 
and  infants.     They  cry  "vrhen  handled,  and  resist  all  examination. 

Fig.  197. 


^^ 


Multiple  neuritis  in  a  child  two  and  one-half  years  of  age.     Shows  the  complete  relaxa- 
tion of  the  glutei  muscles.     Recovery. 


In  older  children  pressure  on  the  nerve-trunk  at  their  point  of  expo- 
sure underneath  the  skin,  such  as  in  the  popliteal  space  or  in  the 
sacro-iliac  groove,  is  exceedingly  painful.  The  complete  recovery 
in  favorable  cases  without  paralysis  or  paresis  diflFerentiates  it  from 
poliomyelitis. 

Treatment. — The  treatment  is  palliative,  since  the  disease  is  not 
only  self-limited,  but  also  tends  to  spontaneous  recovery.     The  pain 


EBB'S  PALSY.  857 

is  relieved  and  the  skin  kept  in  good  condition  by  massage.  If  the 
child  is  restless,  it  is  treated  in  the  ordinary  way.  There  is  no 
specific  for  the  affection.  Electricity  is  not  recommended  by  those 
whose  experience  gives  weight  to  an  opinion.  If  contractures  result, 
orthopedic  appliances  are  indicated  as  in  other  paralytic  diseases. 

ERB'S  PALSY. 

(Obstetrical  Falsy.) 

This  form  of  palsy,  which  occurs  in  infants  and  children  as  well 
as  in  adults,  is  due  to  a  neuritis  caused  by  direct  traumatism  either 
to  the  nerves  supplying  the  muscles  of  the  shoulder,  or  as  in  the 
newly  born  infant  by  traction  or  pressure  on  the  brachial  plexus. 
Erb  showed  that  the  point  injured  in  these  cases  is  the  spot  between 
the  scaleni  at  the  exit  of  the  fifth  and  sixth  cervical  nerve  roots. 
Duchenne,  Seeligmiiller,  and  Henoch  have  described  these  birth  cases 
in  infants.  I  have  seen  cases  in  older  children  which  correspond  to 
the  adult  cases. 

Symptoms. — The  symptoms  are  very  characteristic.  There  is 
complete  paralysis  of  the  arm  on  the  affected  side.  The  child-  if 
directed  to  raise  the  arm  or  forearm,  is  unable  to  do  so.  The  fingers 
can  be  moved.  Infants  sometimes  hold  the  paralyzed  arm  with  the 
healthy  one.  In  a  few  cases  there  seems  to  be  pain,  caused  by  the 
drag  of  the  paralyzed  member  on  the  shoulder.  After  a  time  there 
is  atrophy  of  the  deltoid  and  other  muscles  about  the  shoulder- 
joint,  which  causes  the  bony  prominences  to  show  markedly  (Plate 
XXXVIII.).  The  atrophy  sometimes  comes  on  very  rapidly.  In 
infants  and  children  it  is  impossible  to  reach  any  conclusion  in  regard 
to  the  intensity  of  pain  and  the  disturbances  of  sensation. 

Diagnosis. — The  cases  should  be  differentiated  from  cerebral  birth 
palsies.  Apart  from  the  electrical  reaction,  the  absence  of  hemi- 
plegia or  diplegia  of  a  spastic  nature  with  rigidity,  the  absence  of 
increased  reflex,  and  also  of  convulsions,  all  of  which  are  present  in 
birth  palsies,  will  aid  in  the  diagnosis.  Later  in  life  it  may  not  be 
possible  to  determine  which  form  is  present. 

Prognosis. — The  prognosis  is  good,  but  I  have  seen  severe  cases  of 
obstetrical  palsy  which  failed  to  recover. 

Treatment. ^The  treatment  depends  on  the  origin  of  the  palsy. 
If  it  is  obstetrical,  the  arm  should  be  put  in  an  apparatus  to  protect 
it  from  injury.  After  two  weeks,  friction,  massage,  and  a  mild 
electrical  current  of  the  faradic  variety  should  be  applied.  If  con- 
tractures develop  later,  splints  should  be  constructed  to  counteract  the 
tendency.     On  the  whole,  the  management  of  the  cases  is  based  on 


858  DISEASES  OF  TEE  NEBVOUS  SYSTEM. 

the   principles   whicli  govern  the  treatment   of  peripheral   palsies. 
Later  on  surgical  treatment  by  nerve  anastomosis  may  be  indicated. 

HEREDITARY  ATAXIA. 

(Friedreich's  Disease;   Hereditary   Ataxic   Paraplegia.) 

This  is  a  form  of  ataxia  which  frequently  affects  several  members 
of  the  same  family.  Riitimeyer  and  Griffith  collected  233  cases 
which  were  distributed  in  107  families.  In  38  cases  there  was  a 
direct  hereditary  history.  In  the  remainder  there  was  a  history  of 
alcoholism,  syphilis,  or  consanguineous  marriage.  Sixty-five  cases 
of  Gowers  were  distributed  among  19  families.  Thus  there  was  an 
average  of  3  to  each  family.  In  some  families  there  were  10  cases. 
Isolated  cases  are  rare,  and  occur,  as  a  rule,  only  in  children.  The 
disease  affects  the  sexes  equally.  Cases  have  occurred  as  early  as 
the  second  year,  and  as  late  as  the  twenty-fourth,  but  are  seen  most 
frequently  between  the  seventh  and  eighth  years. 

Symptoms. — The  onset  of  the  disease  may  be  gradual  or  abrupt. 
The  first  symptom  is  an  impairment  of  coordination  in  the  lower 
extremities.  The  patient  is  unsteady  in  walking,  and  stands  with 
the  feet  wide  apart.  Some  patients  reel  when  the  eyes  are  closed 
more  than  at  other  times.  In  other  cases  Romberg's  symptom  is 
absent.  The  feet  show  the  peculiar  deformity  of  pes  cavus.  The 
instep  is  high  and  the  toes  over-extended.  The  movements  of  the 
arms  next  become  ataxic.  The  speech  becomes  slow  and  halting. 
Jerking,  nodding  movements  of  the  head  set  in.  Irritability  of 
muscle  is  absent  from  the  beginning.  The  deep  reflexes  may  be 
present  at  first,  but  finally  disappear  as  in  true  tabes. 

iKystagmus  is  usually  present,  and  may  be  a  very  early  symptom, 
appearing  simultaneously  with  the  ataxic  symptoms.  The  symp- 
toms connected  with  the  speech  may  come  on  very  late  in  the  disease. 

Optic  atrophy  is  never  present,  and  the  Argyll-Eobertson  pupil 
of  tabes  is  absent. 

Sensory  disturbances,  such  as  shooting  pains,  are  rare,  but  may 
occur.  There  is  no  tendency  to  trophic  joint-affection  as  in  tabes. 
The  sphincters  are  normal. 

Muscular  power,  although  normal  at  first,  diminishes  as  the  dis- 
ease progresses.  There  is  atrophy  of  muscle.  Spinal  curvatures, 
talipes  equinus,  and  equinovarus  result.  The  loss  of  muscular  power 
is  sometimes  limited  to  the  lower  extremities. 

The  mental  condition  is  generally  affected.  The  children  are 
slow  at  school.     Imbecilit}^  has  been  recorded  (Gowers). 

Course, — Once  inaugurated,  the  disease  is  progressive,  but  it  may 
remain  stationary  at  any  stage  for  some  years.     The  duration  is 


ACUTE  ENCEPHALITIS.  859 

extended  over  years.  Gowers  gives  the  period  as  ten  to  tv^^elve  years. 
The  patients  finally  become  bedridden,  and,  as  a  rule,  die  from  inter- 
current disease.  The  anatomical  changes  have  not  as  yet  been  com- 
pletely classified.  This  is  due  to  the  fact  that  in  certain  forms  of 
hereditary  ataxia  resembling  Friedreich's  disease,  Marie  and  Hoff- 
mann have  described  changes  other  than  those  found  in  typical  cases 
of  that  affection.  The  changes  in  Friedreich's  disease  consist  in  a 
diminution  in  the  transverse  diameter  of  the  cord  and  a  sclerosis  of 
the  posterior  and  lateral  columns,  involving  the  pyramidal  tracts. 
The  neuroglia  and  vessels  of  the  tracts  are  involved ;  v^hether  this  is 
due  to  an  arrest  of  development  of  a  congenital  nature  has  not  been 
determined. 

Differential  Diagnosis. — The  disease  should  be  differentiated  from 
ti'ue  tabes.  In  the  latter  there  are  the  Argyll-Eobertson  pupil  and 
optic  neuritis,  the  visceral  crises  and  shooting-pains,  but  neither  head- 
nodding  nor  nystagmus.  The  lack  of  intelligence  and  the  family  his- 
tory are  characteristic  of  Friedreich's  disease. 

Prognosis  and  Treatment. — There  is  no  cure  for  the  affection. 
The  treatment  is  designed  to  relieve  the  symptoms. 

ACUTE  ENCEPHALITIS. 

Synonyms.. — Acute  Polioencephalitis,  superior  or  inferior  (Wer- 
nicke), Acute  Hemorrhagic  Cortical  Encephalitis. 

Etiology." — Encephalitis,  or  acute  polioencephalitis,  is  an  acute 
infectious  disease,  though  the  exact  exciting  cause  is  still  unknown. 
It  was  first  described  by  Striimpel,  Leichtenstein,  and  Oppenheim. 
It  may  complicate  or  follow"  the  exanthemata,  influenza,  pneumonia, 
erysipelas,  diphtheria,  septic  endocarditis,  or  forms  of  otitis.  I 
have  seen  two  cases  follow  varicella.  It  may  follow  ptomaine  poi- 
soning, or  poisoning  by  alcohol,  or  wood  alcohol,  or  carbonic  dioxide. 
A  traumatism  of  the  head  may  be  a  predisposing  factor.  It  is  a  dis- 
ease of  infancy  and  childhood,  but  may  occur  in  adults. 

Forms. — It  may  involve  any  part  of  the  brain.  Striimpel  de- 
scribed it  as  a  cortical  lesion,  Wernicke  as  an  affection  of  the  gray 
matter  in  the  aqueduct  of  Sylvius,  or  the  disease  may  affect  the 
nuclear  deposits  in  the  medulla  and  according  to  distribution  is  called 
polioencephalitis,  superior  or  inferior.  In  such  cases  there  is  an 
acute  bulbar  paralysis.  In  other  cases  the  disease  may  affect  a  small 
area  of  the  brain ;  or  the  two  hemispheres  in  both  gray  and  white  sub- 
stance ;  or  it  may,  as  above,  involve  the  medulla,  the  upper  part  of 
the  cord,  and  cerebellum.  Thus  the  symptoms  will  differ  according 
to  the  area  of  the  brain  and  medulla  affected. 

Morbid  Anatomy.— The  changes  found  in  the  brain-substance  and 
cortex  are  similar  to  those  described  as  occurring:  in  the  various 


860  DISEASES  OF  lEE  XEBVOUS  SYSTEM. 

forms  of  poliomyelitis.  There  is  an  acute  hyperemia  starting  from 
the  pia  mater  with  distention  of  the  bloodvessels  and  rupture  and 
hemorrhages  into  the  brain-tissue  with  infiltration  of  cells  and  leuco- 
cytes. There  are  various  degrees  of  degeneration  and  destruction 
of  nerve-tissue,  neurones,  axones,  and  dendrites.  The  changes  are 
identical  with  those  of  poliomyelitis.  After  the  acute  stage  has 
passed,  absorption  of  cells  and  clots  takes  f)lace  and  if  the  destruction 
of  tissue  has  not  been  diffuse  or  in  important  foci,  no  trace  is  left 
behind.  On  the  other  hand,  if  important  areas  have  been  inflamed 
and  destroyed,  paralyses  of  varying  extent  are  left,  or  if  large  cere- 
bral areas  have  been  involved,  imbecility  or  blindness  may  result. 
Among  the  foci  there  may  be  facial  paralysis,  varying  ocular  palsies, 
hemiplegia,  and  monoplegia.  Cerebellar  lesions  lead  to  ataxia  and 
in  cord  involvement  symptoms  referable  to  the  cord  remain.  In  one 
of  my  cases  total  blindness,  which  in  the  course  of  months  improved, 
resulted;  in  another,  a  mild  form  of  strabismus;  in  a  third,  a  left 
facial  and  arm  paralysis ;  and  a  fourth  recovered  without  any  pareses. 
The  subsequent  formation  of  connective  tissue  in  the  brain  or  cord 
may  lead  to  epilepsy  or  multiple  sclerosis  of  the  cord. 

Symptoms. — There  are  two  sets  of  symptoms :  those  of  the  onset 
and  those  due  to  the  part  of  the  brain  affected.  The  history  in  most 
cases  is  similar.  There  may  be  a  few  days  of  indisposition,  head- 
ache, and  dizziness,  followed  by  sudden  vomiting,  a  chill  or  convul- 
sions, and  then  the  patient  passes  into  a  condition  of  stupor  or  coma 
with  a  temperature  which  may  be  at  first  as  high  as  104°  and  then 
falls  to  the  normal,  or  may  be  at  times  a  degTee  or  half  a  degree 
above  the  normal.  In  the  stage  of  stupor  or  coma  there  is  delirium, 
hypersesthesia,  and  restlessness,  which  may  last  with  intervals  of  quiet 
for  one  or  two  or  even  three  weeks. 

In  all  my  cases  it  was  fairly  impossible  at  first  to  differentiate 
the  symptoms  from  those  of  a  meningitis.  In  one  instance  the  diag- 
nosis of  tuberculosis  and  in  another  that  of  cerebrospinal  meningitis 
was  made.  I  uniformly  found  neck-rigidity,  tacJie  cerebrate,  and 
Kernig's  sjmiptom  with  hypera?sthesia.  There  was  a  mild  degTee  of 
internal  hydrocephalus  as  evinced  by  the  Macewen  sign  and  a  subse- 
quent maudlin  form  of  delirium.  Once  there  was  monoplegia  of  the 
left  upper  extremity,  choked  disc,  and  temporary  blindness  and  stra- 
bismus. In  another  case  there  was  o])tic  atrophy  and  a  complete 
blindness  which  improved  in  months.  In  a  third  case  a  period  of 
maudlin  delirium  occurred  followed  by  complete  recovery  without 
any  pareses.  In  every  instance  I  found  that  there  was  a  leucocytosis 
of  the  polynuclcar  type,  from  24,000  or  30,000  to  Y2,000  white  cells 
to  the  cubic  millimetre. 

Aphasia,  temporary  or  permanent,  may  result  or  some  form  of 


ACUTE  POLIOMYELITIS.  861 

word-blindness,  hemianopsia,  or  permanent  deafness,  or  blindness,  as 
in  one  of  mj  cases.  Idiocy  may  result.  Starr  reports  a  case  in 
which  there  were  symptoms  of  cerebellar  type,  such  as  tremors  of  the 
hands  and  lower  extremities.  Again,  with  the  symptoms  referable 
to  eyesight,  there  may  be  ocular  palsies,  ptosis,  strabismus,  or  ophthal- 
moplegia. In  another  set  of  cases  there  are  symptoms  denoting 
bulbar  paralysis,  such  as  disturbances  of  speech,  deglutition  and 
respiration;  in  other  words,  glosso-labio  laryngeal  paralysis.  Here 
the  danger  of  a  fatal  issue  is  gTcat.  Lumbar  puncture  in  my  cases 
revealed  a  clear  fluid  with  few  flocculi,  having  a  cytosis  of  100  per 
cent,  lymphocytes,  containing  sugar  and  albumin. 

Prognosis. — The  prognosis  as  to  life  is  good  in  most  cases  except 
such  as  show  bulbar  symptoms,  which  may  by  involving  the  respira- 
tory centres  cause  death.  Epilepsy  may  follow  later  in  life,  espe- 
cially in  children  in  whom  the  cortex  of  the  brain  has  been  severely 
involved.  These  cases  include  the  so-called  cortical  epilepsy  with 
sensory  or  motor  aura  (Starr).  A  mild  form  of  mental  deficiency 
or  complete  imbecility  may  sometimes  result. 

Treatment. — In  the  acute  stage,  sedatives  such  as  bromides  and 
opium  are  indicated  and  cups  to  the  nape  of  the  neck  and  spine.  Hot 
baths  are  comforting,  especially  where  pain  in  the  spine  and  extremi- 
ties is  complained  of.  When  the  acute  stage  has  passed,  the  general 
symptomatic  treatment  as  in  poliomyelitis  is  indicated.  Patients 
should  not  be  released  from  observation  until  it  is  certain  that  all 
danger  from  relapses,  which,  though  rare,  have  occurred,  is  passed. 
In  one  of  my  cases  blindness  was  discovered  four  weeks  after  the 
patient  was  thought  to  be  apparently  well. 

Lumhar  Puncture. — Lumbar  puncture  is  permissible  in  the  acute 
stage  of  delirium  and  has  a  quieting  eif ect  on  the  patient.  It  has 
been  recently  proposed  by  Gushing  to  give  all  acute  infectious  cere- 
bral cases  urotropin.  This  may  be  tried  with  a  view  to  limiting  the 
infective  process  through  the  cerebrospinal  fluid  which  has  been  found 
to  contain  the  drug  a  few  minutes  after  its  administration  by  the 
mouth.  Where  coma  is  complete  and  there  are  signs  of  respiratory 
or  cardiac  failure,  lumbar  puncture  is  attended  with  danger  of  sudden 
death. 

ACUTE  POLIOMYELITIS. 

Synonyms. — Anterior  poliomyelitis,  epidemic  poliomyelitis,  acute 
atrophic  paralysis,  essential  paralysis  of  children,  infantile  paralysis. 

Definition. — Poliomyelitis  is  an  acute  infectious  disease,  whose 
main  characteristic  is  a  flaccid  paralysis  of  wide  or  limited  extent, 
occurring  within  a  few  hours  or  days.  Some  of  the  paralyzed  mus- 
cles recover,  others  undergo  atrophy. 


862  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Occurrence. — This  is  the  most  common  form  of  paralysis  in  chil- 
dren. It  is  questionable  whether  it  occnrs  in  foetal  life.  Duchenne 
reports  the  case  of  an  infant  twelve  days  old,  but  such  cases  are  apt 
to  be  examples  of  cerebral  hemorrhage.  It  usually  occurs  in  the 
first  three  years  of  life.     Both  sexes  are  equally  affected. 

Etiology. — The  etiology  of  this  disease  is  still  obscure.  Though 
most  observers  concede  its  infectious  nature,  no  specific  organism 
has  as  yet  been  positively  identified  as  causative.  Geirsvold  isolated 
a  diplococcus  from  the  throats  and  spinal  fluid  of  patients  sufi:"ering 
from  the  disease  and  Harbitz  and  Scheele  found  a  similar  organism 
in  three  cases.  They  could  not  reproduce  the  disease  experimentally. 
As  predisposing  causes  may  be  cited  exposure  to  cold  and  disturb- 
ances of  the  gastro-enteric  tract.  Medin,  Strlimpel,  and  Zuppert 
found  many  cases  occurred  in  connection  with  the  infectious  dis- 
eases, especially  cerebrospinal  meningitis,  measles,  and  scarlet  and 
typhoid  fever. 

In  the  great  jSTew  York  epidemic,  of  the  two  thousand  cases  re- 
ported, fully  60  per  cent,  showed  some  disturbance  of  the  intestinal 
functions,  either  preceding  or  accompanying  the  onset.  The  disease 
may  occur  sporadically  or  in  epidemics.  The  most  extensive  epi- 
demics have  been  reported  in  Sweden  and  the  United  States.  The 
epidemic  in  ISTew  York  and  its  environs  in  the  summer  of  1907  num- 
bered some  two  thousand  cases.  In  the  years  following  the  !N"eAv 
York  epidemic  there  has  been  a  marked  prevalence  of  the  disease, 
beginning  in  mid-summer  and  extending  into  the  autumn  months  in 
the  localities  aft'ected  by  the  original  outbreak. 

Morbid  Anatomy. — Harbitz  and  Scheele  have  described  the  appear- 
ance in  the  brain  and  cord  of  cases  occurring  in  the  Swedish  epidemics. 

In  the  nervous  system  they  found  in  the  sj)inal  cord  a  diffuse 
inflammation,  chiefly  in  the  gray  matter  and  within  this  chiefly  in 
the  anterior  horn. 

The  inflammation  could  also  be  traced  more  or  less  in  the  white 
matter  and  in  the  pia  mater,  and  esj^ecially  in  the  medulla  oblongata. 
Grossly  speaking  the  inflammation  extended  along  the  whole  length 
of  the  cord  and  was  most  extensive  in  the  cervical  and  lumbar  enlarge- 
ments. There  was  cellular  infiltration  of  small  and  large  mononu- 
clear lymphocytes,  especially  in  the  pia  mater  and  white  substance, 
with  polj'morphonuclear  leucocytes ;  in  the  cord  substance  there  was 
cellular  infiltration ;  the  ganglion  cells  were  markedly  degenerated  ; 
over  large  areas  of  the  cord,  instead  of  the  degenerated  and  disinte- 
gi-ated  ganglion  cells,  there  were  so-called  neurophagons  or  leucocytes. 
In  the  cases  which  gave  a  clinical  appearance  of  bulbar  paralysis  there 
was  diff"use  infiltration  all  along  the  cord,  often  of  a  hemorrhagic 
character.     Small  hemorrhagic  cavities  were  found  especially  in  the 


ACUTE  POLIOMYELITIS.  863 

anterior  horn,  with  extensive  destruction  of  nerve-tissue  elements. 
The  pi  a  mater  was  distinctly  inflamed  and  the  inflammation  seemed 
to  extend  from  the  pia  into  the  substance  of  the  cord. 

The  inflammation  reaches  its  highest  intensity  in  the  anterior 
horns  because  they  are  supplied  from  numerous  large  bloodvessels. 
The  infiltration  of  the  pia  extended  to  the  medulla  and  pons  and  cere- 
bellum, especially  in  the  mesial  line  along  the  base  of  the  brain,  and 
to  the  vessels  at  the  base  and  the  Sylvian  fissure.  The  infiltration  of 
the  pia  could  be  traced  over  the  surface  of  the  brain  and  in  the  sulci, 
central  foramen  and  median  fissures. 

The  Brain. — There  was  more  or  less  encephalitic  infiammation 
about  the  medulla  and  pons,  especially  about  the  fourth  ventricle  and 
in  the  substantia  reticularis  and  in  most  of  the  nuclei  of  the  cranial 
nerves.  The  inflammation  was  particularly  marked  around  the 
blood-vessels  from  the  anterior  surface  through  the  raphe ;  the  lower 
part  of  the  pons  and  medulla  were  much  less  involved,  as  also  the 
pyramids,  olives,  crura  and  the  anterior  surface  of  the  pons. 

The  inflammation  also  was  of  a  hemorrhagic  character,  but  not 
so  intense  as  that  found  in  the  cord,  with  considerable  oedema  at  the 
bottom  of  the  fourth  ventricle.  In  the  cases  where  the  symptoms 
were  due,  it  was  believed,  to  acute  bulbar  paralysis,  the  basal  ganglion 
were  involved  in  inflammation. 

The  largest  infiltrations  were  found  in  the  lower  part  of  the  optic 
thalamus.  The  white  substance  of  the  external  and  internal  capsules 
were  generally  involved  to  a  more  or  less  extent. 

Certain  parts  of  the  pia  were  involved  and  the  inflammation 
seemed  to  extend  from  the  pia  into  the  brain  substance.  There  were 
small  perivascular  infiltrations.  There  were  also  numerous  large 
infiltrations  in  the  cortex  of  the  central  gyri  with  slight  degeneration 
of  the  ganglion  cells.  The  frontal  gyri  were  involved,  especially  the 
posterior,  and  on  the  median  surface  much  more  than  the  outer  lobe 
and  gyri. 

In  a  severe  and  fatal  case  of  acute  poliomyelitis  there  was  dif- 
fused inflammation  of  the  entire  cord,  pia  mater,  medulla  and  pons^ 
of  the  basal  ganglia  and  often  of  the  cortex  of  the  brain  to  a  greater 
or  less  extent.  In  those  with  limited  paralyses  the  same  changes 
could  be  demonstrated  to  a  less  degree  in  the  cord,  the  basal  ganglia 
and  medulla  and  in  a  few  cases  in  the  cortex  of  the  brain,  thus  proving 
that  poliomyelitis  is  rather  a  general  process  even  in  the  milder  cases. 

It  has  been  thought  in  various  epidemics  that  in  such  ascending 
paralyses  as  Landry's  paralysis,  followed  by  bulbar  symptoms  and 
death,  that  the  inflammatory  process  extended  from  the  cord  to  the 
medulla.  This  is  erroneous,  as  such  apparent  communications  do 
not  exist.     The  cord  and  medulla  are  infected  from  the  meninges 


864  DISEASES  OF  TEE  NEBVOUS  SYSTEM. 

along  the  bloodvessels.  A  large  percentage  of  cases  of  Landry's 
paralysis  have  been  shown  to  be  of  the  nature  of  a  severe  poliomy- 
elitis, with  extension  to  the  medulla. 

In  four  cases  of  bulbar  paralysis  which  these  authors  examined 
and  which  were  fatal,  the  bulbar  symptoms  being  severe  dyspnoea, 
cyanosis,  difficulty  in  micturition,  deglutition,  articulation,  and  paral- 
ysis of  the  soft  palate  and  of  the  ocular  muscles,  there  was  severe  and 
intense  inflammation  of  medulla  oblongata,  with  considerable  destruc- 
tion of  cord,  giving  the  same  appearance  as  that  of  any  beginning 
poliomyelitis  of  a  hemorrhagic  nature.  At  the  same  time  there  was 
similar  inflammation  in  the  cord  often  less  intense. 

Anatomically  these  cases  do  not  differ  from  ordinary  cases  of 
acute  poliomyelitis,  the  difl^erence  being  only  in  distribution  and 
degree  of  the  intensity  of  the  inflammatory  process. 

Symptoms. — The  general  symptoms  divide  themselves  into  four 
distinct  periods :  those  of  the  onset;  the  paralysis ;  the  period  of  retro- 
gression, in  which  some  of  the  paralyzed  parts  recover,  others  remain- 
ing paralyzed;  and  finally  the  period  of  permanent  paralysis  and 
atrophy  of  muscle. 

Onset. — The  onset  is  acute  but  there  may  be  indefinite  symptoms 
for  some  days  preceding.  The  onset  may  be  followed  by  remission 
of  symptoms  and  then  new  symptoms  may  appear  after  a  few  days. 
Fever  is  among  the  first  symptoms  with  or  without  convulsions  or 
vomiting.  These  are  followed  by  sopor,  which  may  deepen  into  coma. 
Headache,  mostly  of  an  occipital  character,  may  accompany  the 
fever.  Cerebral  symptoms  may  be  present,  consisting  of  pain  in  the 
nape  of  the  neck,  sensitiveness  over  the  spinous  processes,  sometimes 
accompanied  by  hypersesthesia  or  retraction  of  the  head  or  orthotonos 
lasting  over  a  week.  The  pains  are  of  short  duration  and  may  sub- 
side with  the  fever  or  they  may  persist  for  a  week  or  more.  The 
pains  sometimes  radiate  into  the  extremities,  but  are  unaccompanied 
by  joint  involvement.  There  are  frequently  sensitiveness  of  nerve 
and  muscle.  Tremors  may  be  an  early  symptom,  as  well  as  ataxia, 
the  latter  being  uncommon. 

Gastro-enteric  disturbances,  such  as  severe  vomiting  and  diarrhoea 
with  fetid  discharges,  are  quite  common,  and  at  other  times  there  is 
a  history  of  inordinate  constipation. 

During  the  initial  period  incontinence  of  urine  for  three  or  four 
days  has  been  observed. 

Forms  of  the  Disease  at  the  Onset. — The  disease  may  be 
clinically  divided  into  distinct  forms  according  to  the  predominance 
of  one  or  the  other  set  of  symptoms  of  the  onset. 

1.  The  polioniyolitic  or  spinal  form. 


ACUTE  POLIOMYELITIS.  865 

2.  The  form  simulating  an  acute  ascending  or  descending  paral- 
ysis (Landry's  paralysis). 

3.  The  bulbar  or  pontine  form. 

4.  The  encephalitic  or  cerebral  form. 

5.  The  polyneuritic  form. 

6.  Abortive  forms. 

Some  also  mention  the  ataxic  form,  but  this  is  rare. 

1.  Poliomyelitic  Form. — The  poliomyelitic  form  is  that  which 
has  always  been  known  as  anterior  poliomyelitis  and  was  so  described 
by  Charcot.  This  is  a  paralysis  flaccid  in  character  appearing  after 
an  initial  fever  and  vomiting  and  which  is  purely  a  motor  paralysis. 
Two  or  three  days  after  the  onset  there  is  a  paralysis  which  at  first 
may  be  incomplete.  In  some  cases  the  paralysis  goes  no  further  and 
may  even  improve,  in  others  there  is  a  progressive  involvement  of  one 
or  more  extremities.  For  the  most  part  only  certain  groups  of  mus- 
cles are  affected,  such  as  the  peroneal  gTOup ;  the  quadriceps  femoris : 
and  the  shoulder  group,  including  the  deltoid,  the  extensors  or 
flexors.  The  paralysis  may  be  partial  or  complete,  and  may  amount 
to  monoplegia  or  paraplegia,  and  in  the  acute  stage  it  may  be  more 
decided  than  later  on. 

2.  Form  Simulating  Landry's  Paralysis. — The  second  form  is 
that  which  simulates  an  ascending  or  descending  progTessive  paral- 
ysis, such  as  has  been  known  under  the  title  of  Landry's  paralysis. 
This  form  of  poliomyelitis  numbers  among  its  cases  many  which  are 
fatal.  Wickman  found  among  159  fatal  cases  36  of  this  form.  In 
children  it  is  recognized  with  great  difficulty  because  in  the  initial 
period,  the  patients  being  confined  to  their  bed,  the  beginning  paral- 
ysis is  not  noticed.  Thus  many  eases  of  this  form  are  generally  not 
diagnosed  in  children.  In  adults  a  more  complete  history  is  obtain- 
able and  more  cases  of  this  form  are  therefore  observed  at  this  time 
of  life. 

3.  Bulbar  or  Pontine  Form. — In  this  form  the  nuclear  involve- 
ment in  the  medulla  takes  a  leading  role  in  the  symptomatology  fol- 
lowing the  immediate  onset.  The  initial  symptoms  begin  with  fever, 
chills,  and  pains  in  the  head,  neck  and  back.  There  is  vomiting, 
neck-rigidity  and  spinal  tenderness.  The  movements  of  the  extremi- 
ties are  painful  and  there  is  sensitiveness  of  the  nerve-trunks.  The 
nuclear  palsies  which  are  so  characteristic  of  this  form  may  be  accom- 
panied by  a  paresis  or  paralysis  of  one  or  other  extremity  or  of  the 
muscles  of  the  abdomen  or  back.  The  patients  cannot  sit  up  or  hold 
the  head  up. 

There  are  ocular  palsies  and  the  face  may  be  involved.  The 
intercostal  muscles  may  be  paralyzed  and  also  those  of  the  abdomen. 
The  breathing  is  then  purely  diaphragmatic  with  protrusion  of  the 


866 


DISEASES  OF  THE  KEEVOrS  SYSTEM. 


Fig.  198. 


abdomen  with  each  descent  of  the  diaphragm  and  marked  by  labored 
alffi  nasi.  The  ocnlar  j)alsies  vary  from  an  abducens  paralysis  to 
complete  ophthalmoplegia.  Hypoglossal  paralysis,  or  paralysis  of 
the  soft  palate,  may  be  present.  If  there  is  glosso-labio-laryngeal 
paralysis,  there  is  difficulty  in  swallowing.  Only  half  of  the  tongue 
may  be  protruded  or  the  paralysis  may  involve  the  respiratory  nuclei. 
If  the  oculomotor  and  abducens  nucleus  are  affected  ophthalmoplegia 
results.  Medin  records  such  a  case  and  I  have  seen  one  in  the  Xew 
York  epidemic.  If  the  celiospinal  centre  is  involved  there  is  the 
Oppenheim  symptom  of  a  narrowing  of  the  ocular  fissure  and  pupil 
of  the  eye  on  the  paralyzed  side.  Optic  atrophy  or  amaurosis  may 
occur. 

If  the  ninth,  tenth  and  eleventh  nerves  are  affected  deglutition  is 
disturbed  with  the  pharyngeal  paralysis.     Cheyne-Stokes  respiration 

may  be  seen  as  a  result  of  an  affection  of 
the  respiratory  centre  and  involvement 
of  the  accessorius. 

The  clinical  history  of  this  form  of 
poliomyelitis  very  closely  resembles  the 
condition  described  as  polioencephalitis. 
The  patient  is  taken  with  vomiting  and 
fever.  The  latter  continues,  though  the 
vomiting  may  cease  or  become  incessant, 
.^fter  a  day  or  two  of  fever  it  is  noticed 
that  there  is  a  weakness  in  the  extremi- 
ties and  the  patient  takes  to  bed.  Sopor 
now  sets  in  and  increases,  or  it  may  alter- 
nate with  restlessness  or  delirium.  It  is 
now  noticed  that  the  patient  swallows 
with  difficulty  and  may  have  spasms  of 
choking  if  any  fluid  is  swallowed.  There 
is  shallow  respiration.  The  fever  after 
a  few  days  subsides  to  the  normal  and  an 
examination  shows  the  patient  to  be  soporose,  though  roused  on  inter- 
ference. There  is  irritability.  Xuclear  palsies,  such  as  facial  palsy 
or  strabismus,  and  abdominal  breathing,  may  be  marked  on  account 
of  the  paralysis  of  the  muscles  of  respiration  (Fig.  198).  Rales 
and  rhonchi  appear  in  the  chest.  There  is  mild  hydrocephalus  in 
many  cases.  The  patient  may  recover  in  this  stage  or  go  on  to  more 
complete  bulbar  paralysis  and  death.  There  may  in  this  form  be  no 
paralysis  of  the  extremities,  though  a  weakness  is  present.  The 
knee  jerks  are  increased.  There  may  be  slight  monoplegia  of  either 
upper  extremity. 


I'olioiiiyelitis  involving  only 
the  facial  nerve.  Encephalitic 
and  bulbar  type. 


ACUTE  POLIOMYELITIS.  867 

4.  Encephalitic  or  Cerebral  Form. — The  encephalitic  or  cerebral 
form  is  that  in  which  the  onset  is  characterized  bv  meningeal  symp- 
toms. There  are  pain,  headache,  neck-rigidity,  and  even  uncon- 
sciousness. In  some  cases  these  symptoms  soon  subside  on  the  ap- 
pearance of  the  paralysis,  in  others  they  persist  and  take  a  leading 
role,  so  that  at  first  it  is  almost  impossible  to  decide  whether  there  is 
a  true  meningitis  or  not.  Some  days  must  elapse  before  such  a  dif- 
ferential diagnosis  is  possible  and  in  many  cases  a  lumbar  puncture 
must  be  performed  to  decide  the  question. 

5.  Polyneuritic  Form. — The  polyneuritic  form  has  caused  much 
discussion  as  to  whether  there  can  be  true  neuritis  in  such  cases. 
The  truth  is  that  in  some  cases  it  is  almost  impossible  to  differentiate 
and  to  decide  as  to  the  presence  of  a  neuritis.  The  pains  which  have 
been  mentioned  are  prominent  symptoms  combined  with  extreme  sen- 
sitiveness of  nerve  and  muscle.  In  neuritis  there  is  motor  paralysis 
with  complete  recovery  of  muscle ;  the  opposite  is  true  of  poliomyelitis. 

6.  Abortive  Form. — Finally,  in  all  epidemics  of  poliomyelitis, 
alongside  of  the  true  cases  which  have  developed  all  the  symptoms 
of  paralysis,  there  are  the  abortive  cases,  in  which  there  occur  all  the 
symptoms  of  the  onset  of  the  disease,  but  in  which  there  is  no  paral- 
ysis, the  patients  being  ill  but  a  few  days  and  making  a  complete 
recovery.  In  other  words,  there  is  some  general  infection,  but  no 
lasting  symptoms. 

To  illustrate:  a  child  during  an  epidemic  of  poliomyelitis,  after 
an  indefinite  period  of  either  constipation  or  some  disturbances  of 
the  functions  of  the  intestine,  is  taken  with  fever.  This  fever  lasts 
a  few  days;  at  first  it  is  high  and  then  subsides.  There  is  restless- 
ness, crying  out  at  night,  delirium,  and  complaint  of  pain  in  the  back 
of  the  neck  and  head  in  young  children.  There  is  some  rigidity; 
there  is  also  a  slight  increase  of  fluid  in  the  ventricles  of  the  brain, 
as  is  evinced  by  percussion.  There  are  no  paralyses  or  pareses;  at 
most  the  reflexes  at  the  knees  are  increased.  There  is  in  infants  and 
young  children  a  distinct  loss  of  weight.  These  symptoms  may  be 
attended  by  inordinate  and  uncontrolled  vomiting,  lasting  over  days. 
The  patients  recover,  the  disease  leaving  no  trace  behind  except  gen- 
eral weakness.  There  is  thus  a  close  resemblance  between  these 
cases  and  an  encephalitis  of  favorable  issue. 

7.  Ataxic  Form. — In  the  so-called  ataxic  form,  after  the  onset, 
it  is  noticed  that  the  children  have  an  uncertain  gait  and  walk  with 
limbs  spread  apart,  very  much  as  in  Friedreich's  ataxia.  In  some 
cases  the  patellar  reflexes  are  increased,  in  others  there  is  no  atrophy 
of  muscle.  In  most  cases  the  ataxia  ■  amounts  to  a  paresis  with 
ataxia,  but  there  is  no  isolated  pure  ataxia. 


868 


DISEASES  OF  THE  NEEVOUS  SYSTEM. 


Paralysis. — The  paralysis  is  a  flaccid  paralysis,  a  loss  of  power 
which  is  complete  in  two  or  three  limbs  or  in  parts  of  extremities. 
Seeligmiiller  found  the  right  lower  extremity,  the  left  lower  ex- 
tremity, the  right  upper  extremity,  and  the  left  upper  extremity, 
involved  in  the  order  named.  Medin  found  that  in  a  group  of  65 
cases  the  incidence  of  paralysis  was  as  follows:  both  arms,  20  cases; 
right  lower  extremity,  6  cases;  right  upper  extremity,  2  cases;  right 
arm,  2  cases ;  left  arm,  2  cases ;  arm  and  leg,  1  case ;  leg  and  neck 
muscles,  1  case;  arm,  leg  and  abdominal  muscles,  1  case;  chest  inter- 

FiG.  199. 


Acute  atrophic  paralysis  involving  tlie  left  upper  and  lower  extremities. 

costals,  2  cases;  arm,  lower  extremity  and  buttocks,  2  cases;  neck 
muscles,  2  cases;  muscles  of  the  whole  body,  1  case;  paralysis  of  the 
lumbar  spine  and  al)diicens  nerve,  1  case;  paralysis  of  the  lumbar 
spine  and  oculoinotor  nerve,  1  case;  complete  spinal  paralysis  and 
facial  ))aralysis,  1  case;  complete  spinal  paralysis,  facial  and  occip- 
ital, 1  case;  complete  Innibar  paralysis,  1  case;  and  paralysis  of  facial 
nerves  and  polyneuritis,  1  case. 

The  remainder  of  his  cases  consisted  of  forms  of  ])olyneuritis, 
facial  and  mono])legias,  and  paralysis  of  the  cranial  nerves  with  polio- 
encephalitis. 

Aflci-  llic   fii'-t   (»ii^('1   of  tile  pai-alysis,  some  of  the  ninscles  may 


ACUTE  POLIOMYELITIS. 


869 


recover.  Thus  a  child  who  has  been  unable  to  sit  up  or  move  the 
arms  will  recover  the  power  to  do  so.  In  such  cases  one  leg  only 
may  remain  permanently  paralyzed. 

Paralysis  may  develop  slowly  in  the  course  of  one  or  two  weeks. 
After  that  time  it  comes  to  a  standstill.  In  a  period  of  from  one  to 
three  months  either  recovery  will  take  place  or  the  paralysis  will  be 
complete  with  accompanying  atrophy. 

In  some  forms  of  poliomyelitis,  especially  those  combined  with 
symptoms  of  bulbar  nuclear  involvement,  the  patient,   though  the 

Fig.  200. 


Poliomyelitis  showing  atrophy  of  left   upper   and  lower   extremity   and   trunk  muscles. 

paralysis  at  first  may  have  involved  both  upper  and  lower  extremities, 
the  muscles  of  the  neck,  back,  thorax,  and  even  abdomen,  may  recover 
in  a  few  weeks  or  months  to  the  extent  of  being  able  to  walk  about 
and  use  the  upper  extremities,  but  the  muscles  of  the  back  on  either 
side  may  remain  permanently  involved,  so  as  to  give  rise  to  unsightly 
spinal  curvatures.  In  other  cases  which  at  first  showed  a  general 
widely  distributed  j^aralysis,  there  may  remain  only  a  paralysis  with 
atrophy  of  groups  of  muscles  in  both  upper  extremities.  Thus  the 
eventual  permanent  paralysis  may  in  no  way  be  indicated  by  the 
paralysis  apparent  in  the  early  period  of  the  disease. 


870 


DISEASES  OF  TEE  NEBVOUS  SYSTEM. 


Atrophy. — Atrophy  in  the  paralyzed  muscle  is  very  character- 
istic of  the  disease.  It  may  be  seen  as  early  as  the  first  week.  Ac- 
companying it,  and  appearing  from  the  fifth  to  the  seventh  day,  is 
the  reaction  of  degeneration  in  the  paralyzed  muscle  and  nerve.  The 
faradic  and  galvanic  irritability  of  nerve  and  muscle  are  increased 
for  the  first  two  days.  They  then  rapidly  diminish,  the  former  dis- 
appearing completely.  The  galvanic  irritability  remains  increased 
for  from  two  to  six  months ;  it  then  diminishes,  and  if  the  paralysis  is 
2)ermanent,  disappears  at  the  end  of  one  or  two  years  (Fig.  201).     In 

Fig.  201. 


I'oliomj-elitis. 


Left  facial  paralysis,  left  upper  and  right  lower  extremity  involved 
with   atrophy. 


rare  cases  all  electrical  irritability  disappears  from  the  onset.  In 
others  the  faradic  irritability  in  certain  fibres  and  muscles  returns 
after  from  six  to  twelve  months.  These  muscles  may  partially  recover, 
but  remain  atrophied  and  weak.  There  is  usually  no  loss  of  sensa- 
tion, but  if  it  docs  occur,  there  is  incontinence  of  urine.  Reflex  at 
the  patellar  tendon  is  lost  and  myotonic  irritability  is  either  lost  or 
diminished.  In  cervical  disease  of  the  cord,  or  when  only  the  pos- 
terior tibial  muscle,  or  the  muscles  of  the  feet  are  paralyzed,  the 
tendon  reflex  at  the  knee  is  present  or  increased.  In  rare  cases,  the 
inflammation  may  spread  from  the  anterior  horns  to  the  lateral 
columns.  Thfe  lower  extremities  may  then  be  paralyzed  but  not 
atrophied,  and  clonus  may  be  present. 

Growth  of  bone  is  retarded,  and  one  foot  may  after  a  time  become 
shorter  than  the  other.  The  joints  become  the  seat  of  subluxations 
through  the  laxity  of  the  muscle  and  lack  of  support.  The  articular 
ends  of  the  bones  are  not  held  in  apposition.     Through  the  shorten- 


ACUTE  POLIOMYELITIS.  871 

ing  of  some  muscles  and  the  traction  of  others  there  will  result  various 
forms  of  talipes.  The  muscles  in  front  of  the  tibia  are  affected  more 
than  those  of  the  calf.  The  extensors  of  the  thigh  are  more  fre- 
quently paralyzed  than  the  flexors. 

The  muscles  of  the  whole  arm  may  be  paralyzed,  or,  as  in  Erb's 
paralysis,  only  those  of  the  deltoid  group.  The  serratus,  the  pecto- 
ralis,  the  muscles  of  the  back  and  neck,  and  the  diaphragm  may  all 
be  affected. 

Diagnosis.— The  diagnosis  may  offer  difficulties  in  those  cases 
which  simulate  meningitis  and  neuritis.  The  onset  of  the  disease 
may  mislead  into  the  suspicion  of  an  infectious  disease;  indeed,  at 
first  this  would  seem  the  most  natural  assumption.  The  progress  of 
the  disease  and  the  appearance  of  the  paralysis  will  clear  up  the  diag- 
nosis. The  complete  recovery  in  neuritis,  the  pain  of  neuritis,  and 
the  pain  at  the  nerve  exits,  will  all  aid  in  the  diagnosis. 

The  appearance  of  a  flaccid  paralysis  will  clear  up  the  case. 
Some  of  the  meningeal  forms  are  not  so  easily  differentiated  from 
forms  of  true  meningitis ;  in  fact,  I  have  been  forced  in  some  elusive 
cases  to  make  a  lumbar  puncture  to  clear  up  the  diagnosis,  even  in 
the  face  of  a  paresis  of  the  extremities,  for  this  may  be  present  in 
meningitis.  The  leucocytosis,  which  is  also  present  in  forms  of  polio- 
myelitis, does  not  aid  any  in  the  diagnosis,  as  it  is  similar  to  that  of 
cases  of  meningitis. 

The  differential  diagnosis  of  poliomyelitis  from  cerebral  palsy  is 
also  not  so  easy  at  times.  The  paralysis  in  cerebral  palsy  is  not  a 
flaccid  paralysis  as  in  poliomyelitis.  The  reflexes  are  increased  or 
normal  in  some  cases  of  poliomyelitis  and  therefore,  though  absent 
in  most  cases,  this  absence  may  aid  us  in  differentiating  from  cases 
of  cerebral  palsy.  In  the  latter  disease  the  absence  of  atrophy  of 
muscle  and  the  presence  of  post-hemiplegic  chorea  will  aid  in  the 
differential  diagnosis.  The  diagnosis  of  monoplegia  and  facial  pal- 
sies not  poliomyelitic  in  origin  must  be  made  from  the  history  of 
the  case. 

Prognosis. — The  ]3rognosis  varies  in  the  mild  forms  of  the  disease, 
such  as  the  purely  spinal  form,  and  the  epidemic  types,  such  as  the 
bulbar  and  pontine  and  Landry  type.  The  mortality,  therefore, 
ranges  from  6  to  13  per  cent.,  the  latter  being  the  mortality  in  the 
Swedish  epidemic  recorded  by  Wickman.  A  great  many  cases  make 
a  complete  recovery  without  any  residual  ]3aralysis.  In  these  cases 
are  included  the  abortive  types  described  by  Wickman.  Most  of  the 
deaths  occur  in  epidemics  from  the  fourth  to  the  tenth  day,  so  that 
if  the  case  has  lasted  ten  days,  the  outlook  as  to  life  is  good.  Many 
cases  with  a  complete  paralysis  of  all  four  extremities  recover  with 


872  DISEASES  OF  THE  NESVOVS  SYSTEM. 

an  isolated  paralysis,  or  a  paraplegia  mav  leave  a  monoplegia  or  only 
paralysis  of  a  certain  gTOup  of  muscles.  A  positive  view  should  not 
be  expressed  as  to  ultimate  recovery  until  six  months  have  elapsed 
since  the  onset  of  the  disease.  In  other  words,  the  physician  should 
not  be  too  ready  to  assume  the  hopeless  outlook,  but  rather  encourage 
the  parents  of  the  child  as  to  ultimate  recovery  of  a  paralysis. 

Sequelae. — A  cord  which  has  once  been  the  seat  of  this  disease  is 
naturally  susceptible.  Gowers  states  that  he  has  seen  chronic  disease 
of  the  cord  supervene  later  in  life.  Progressive  muscular  atrophy  or 
lateral  sclerosis  may  at  some  later  time  appear  in  the  cord. 

Treatment. — In  the  stage  of  onset  the  treatment  is  symj)tomatic. 
If  delirium  and  pain  exist  the  coal-tar  drugs,  such  as  phenacetin  or 
aspirin,  may  be  used  in  full  doses.  In  severe  cerebral  symptoms 
lumbar  j)uncture  is  indicated  and  not  only  excludes  meningitis  but 
relieves  the  meningism.  When  the  paralysis  appears  and  pains  still 
continue  warm  baths  offer  great  relief.  Sleep  is  obtained  by  means 
of  chloral  hydrate,  bromides,  or  opium.  The  bowels  at  first  shoidd 
be  well  evacuated  with  calomel  and  during  the  illness  enemata  are 
useful.  The  diet  should  be  light  and  assimilable.  After  the  first 
week,  if  the  constitutional  symptoms  have  subsided  and  the  paralyses 
have  appeared,  strychnine  in  full  doses  is  indicated.  With  the  in- 
ternal administration  of  the  drug  is  combined  a  daily  injection  of  the 
sulphate  of  strychnine  into  the  substance  of  the  paralyzed  muscles. 
Daily  massage  of  the  alfected  muscles  and  mild  faradic  current 
applied  for  five  minutes  daily  Avill  keep  up  the  tonicity  of  the  para- 
lyzed muscle-groups.  In  the  early  stages  dry-cups  applied  to  the 
nape  of  the  neck  and  along  the  si^ine  will,  according  to  some,  be  of 
utility.  In  the  stage  of  muscular  contracture  it  is  well  to  begin 
early  the  application  of  splints  and  orthopedic  braces  to  prevent 
deforming  contractures.  Tenotomy  is  only  called  for  in  extreme 
contracture  of  tendon. 

THE  JUVENILE  FORM  OF  PROGRESSIVE  MUSCULAR  ATROPHY 

(ERB'S  TYPE). 

This  disease  is  characterized  by  a  weakness  and  progressive  wast- 
ing of  certain  muscles.  It  begins  in  childhood  or  early  youth,  and 
involves,  as  a  rule,  the  shoulder-girdle,  the  upper  arm  and  pelvic 
girdle,  and  the  thigh  and  back.  The  muscles  of  the  forearm  and  leg 
remain  for  a  time  intact.  This  atrophy  may  l)e  associated  with  true 
hypertrophy  or  pseudohy])ertrophy  of  some  muscle.  The  pectoralis, 
the  trapezii,  the  latissimi  dorsi,  the  serrati,  the  rhomboids,  the  upper 
arm  muscles  and  supraspinators,  are  apt  to  be  wasted.     The  deltoids, 


PLATE  XXXVIir 


Erb's  Paralysis  in  a  Child  Twenty-six  Months  of  Age. 
Atrophy  of  the  deltoid,  subluxation  of  the  arm;  bony 
prominences  marked. 


PSEUDOHYPERTEOPHIC  MUSCULAE  PARALYSIS.  873 

supraspinati,  and  infraspinati  may  be  normal  or  hypertrophied  for  a 
time.  There  are  no  fibrillar  contractions,  no  disturbances  of  sensa- 
tion, and  no  reactions  of  degeneration  and  visceral  disturbances. 

THE  LANDOUZY  OR  DEJERINE   TYPE  OF   THE  FACIO-SCAPULO- 
HUMERAL   FORM   OF   MUSCULAR   ATROPHY. 

This  form  in  no  way  differs  clinically  or  pathologically  from  the 
juvenile  form  of  muscular  atrophy.  Authors  include  in  this  class 
all  cases  in  which  the  atrophy  begins  in  early  life,  as  a  rule,  in  the 
muscles  of  the  face.  The  patients  have  a  peculiar  expression — so- 
called  "facies  myopathique."  The  lips  are  thickened  (''bouche  de 
tapir  "  or  tapir  mouth) .  The  shoulders  later  become  atrophied.  The 
supraspinati,  infraspinati,  and  the  flexors  of  the  hands  and  fingers 
remain  normal,  as  do  the  muscles  of  deglutition,  mastication,  respira- 
tion, and  the  laryngeal  and  ocular  muscles.  There  are  no  fibrillary 
twitchings.  The  spinal  forms  of  progressive  muscular  atrophy  differ 
from  primary  dystrophy  in  that  the  onset  of  the  latter  affection  is  in 
the  upper  extremities.  The  disease  is  not  hereditary,  and  fibrillary 
twitchings  and  electrical  reactions  of  degeneration  are  absent. 

Both  these  forms  are  probably  clinical  varieties  of  the  pseudo- 
hypertrophic form  of  paralysis, 

PSEUDOHYPERTROPHIC    MUSCULAR   PARALYSIS. 

This  disease  is  characterized  by  a  progressive  change  in  the  size 
of  many  of  the  muscles  of  the  body  and  by  a  diminution  of  their 
power.  It  was  described  by  Duchenne  in  1861.  Since  then  the  most 
notable  work  on  the  subject  has  been  done  by  Gowers,  of  England, 
and  Sachs,  of  this  country.  The  male  sex  is  more  frequently  affected 
than  the  female.  From  two  to  eight  members  of  the  same  family  are 
often  affected.  Isolated  cases  are  uncommon.  The  disease  frequently 
affects  the  members  of  one  sex  in  a  family  group.  It  is  congenital 
but  not  hereditary.  The  antecedent  cases,  if  there  are  such,  can 
usually  be  traced  on  the  mother's  side  of  the  famih'.  The  mother 
may  be  herself  unaffected.  Intemperance  does  not  seem  to  exert  any 
influence  on  the  occurrence. 

Gowers  notes  that  frequent  marriage  of  parties  closely  related 
tends  to  predispose  to  the  development  of  the  disease  in  the  children. 
In  one-third  of  the  cases  the  disease  appears  when  the  child  begins  to 
walk,  and  in  children  who  are  late  in  learning.  It  may  manifest 
itself  in  the  mid-period  of  childhood.  In  another  third  of  the  cases 
the  children  are  in  apparently  good  health  until  the  fourth  or  sixth 
year.  Three-fourths  of  the  cases  show  symptoms  of  the  disease 
before  the  tenth  year.     The  disease  may  not  manifest  itself  until 


874  DISEASES  OF  THE  NEEVOUS  SYSTEM. 

after  puberty,  and  may  only  be  noticed  during  convalescence  from 
some  intercurrent  acute  disease. 

Symptoms. — The  symptoms  are  impairment  of  power  and  change 
in  the  form  of  groups  of  muscles  or  of  single  muscles.  The  impair- 
ment of  power  is  at  first  not  very  apparent.  The  muscles  of  the 
calves  enlarge,  and  show  a  very  characteristic  and  significant  hyper- 
trophy. Mothers  are  at  first  pleased  with  what  appears  to  be  mus- 
cular development  of  the  children  (Gowers).  It  is  then  noticed  that 
although  the  muscles  of  the  calves  and  glutei  are  large,  the  children 
are  easily  fatigued  in  mounting  stairs.  They  fall  easily  and  rise 
with  difficulty.  This  loss  of  power  is  at  first  interpreted  as  weak- 
ness, but  when  it  is  found  to  be  progressive  the  children  are  brought 
to  the  physician. 

The  gait  becomes  pronouncedly  oscillating.  The  body  is  inclined 
so  that  the  centre  of  gravity  is  brought  successively  over  each  foot. 
In  trying  to  rise  from  the  ground  the  patient  places  a  hand  on  each 
knee  in  a  very  characteristic  fashion.  By  grasping  the  thighs  and 
throwing  back  the  weight  of  the  trunk,  the  patient  helps  himself  into 
the  erect  posture.  The  weakness  of  the  muscles  finally  becomes  ex- 
treme. The  patients  can  neither  stand,  walk,  nor  sit  upright.  They 
become  bedridden.  In  the  early  stage,  the  muscles  of  the  trunk  may 
be  normal,  small,  or  atrophied,  and  those  of  the  lower  extremities 
much  enlarged.  Single  muscles  or  groups  of  muscles  of  the  arm  and 
forearm  may  be  enlarged  (Plate  XXXIX.).  Finally,  as  the  atrophy 
and  weakness  increase,  there  are  contractures  and  distortions  of  the 
extremities  and  trunk.  Equinus,  lordosis,  and  lateral  curvature  are 
very  marked.  The  knee  may  become  fixed  and  distorted  by  contrac- 
tures. The  muscles  most  frequently  affected  in  the  beginning  are 
those  of  the  calves  of  the  legs.  These  sometimes  attain  an  enormous 
size.  Those  of  the  anterior  part  of  the  leg  are  not  so  much  enlarged. 
The  flexors  of  the  knee  commonly  escape.  The  glutei  and  lumbar 
muscles  are  enlarged. 

The  infraspinatus  muscle  is  frequently  enlarged,  and  stands  out 
prominently;  it  is  often  mistaken  for  the  lower  edge  of  the  scapula. 
The  deltoid  is  often  large ;  the  serratus  and  the  pectoralis  are  rarely 
affected.  The  triceps  and  biceps  are  frequently  large,  but  often  only 
in  parts.  The  muscles  of  the  forearm  suffer  only  in  a  minority  of 
cases.  The  intrinsic  muscles  of  the  hand  are  never  affected.  In 
that  respect  the  disease  is  sharply  distinguished  from  atrophies  of 
spinal  origin.  The  muscles  of  the  neck  are,  with  the  exception  of 
the  clavicular  portion  of  the  sternomastoid,  rarely  affected.  All  the 
muscles  affected  are  weakened,  the  smaller  and  atrophied  muscles 
more  so  than  the  others.  There  is  reason  to  believe  that  many  mus- 
cles not  visible  are  much  affected. 


PLATE  XXXIX 


Pseudohypertrophic  Paralysis  in  a  Boy  Eight  Years  of  Age. 
Hypertrophy  of  the  infraspinati  well  sho^?vn  ;  also  atrophy  of 
the  muscles  of  the  thorax  and  hypertrophy  of  the  glutei  and 
the  muscles  of  the  lower  extremity. 


PSEUDOHYPEBTBOPHIC  MUSCULAB  PABALYSIS.  875 

Electrical  Reaction. — This  is  altered  when  weakness  sets  in. 
The  electrical  contractility  to  galvanic  and  faradic  stimulus  finally 
disappears. 

Reflexes. — The  knee-jerk  is  at  first  normal.  It  later  diminishes 
and  finally  disappears.  It  is  never  increased  in  a  pure  case.  In  one 
case  in  my  hospital  service  there  were  increased  reflex  at  the  knee 
and  foot-clonus.  This  case  gave  a  history  of  a  blow  across  the  back. 
Sachs,  with  whom  I  saw  the  case,  suspected  a  complicating  myelitis 
of  the  cord. 

Sensation. — Sensation  is  unaffected  and  the  sphincters  remain 
normal. 

Course. — The  course  of  the  affection  is  prolonged  and  tedious. 
The  disease  is  progressive.  It  may  be  ten  or  fourteen  years  before 
the  patients  succumb.  They  die  of  some  intercurrent  disease.  If 
the  disease  appears  after  puberty,  the  course  is  slower  than  in  cases 
in  which  the  first  symptoms  are  noted  in  early  childhood. 

Varieties. — There  are  cases  in  which  only  one  muscle  or  group 
of  muscles  of  the  extremities  is  enlarged,  the  others  being  small  or 
normal  in  size.  There  are  other  cases  in  which  all  the  muscles  are 
small  and  waste  progressively. 

Complications.^ — Chorea,  poliomyelitis,  myelitis,  mental  deficien- 
cies, and  epilepsy  may  complicate  the  affection. 

Morbid  Anatomy. — The  gray  matter  of  the  cord  and  the  nerves 
are  normal  in  appearance.  There  may  be  slight  hemorrhages.  The 
neuroglia-cells  have  sometimes  been  found  to  be  increased.  The 
disease  is,  however,  primarily  one  of  the  muscle-tissue.  The  muscles 
are  pale-yellow.  They  are  replaced  mainly  by  fat  and  connective 
tissue.  The  muscle-fibre  is  narrower  than  is  normal,  although  in 
advanced  cases  the  residual  muscle-fibre  may  retain  its  transverse 
striation.  Where  the  muscle-fibre  is  narrow  it  becomes  granular  or 
is  the  seat  of  fatty  or  waxy  degeneration  and  vacuolization.  Empty 
sarcolemma-sheaths  are  seen. 

Diagnosis.- — The  diagnosis  is  made  from  the  progressive  weak- 
ness, the  gait,  and  the  mode  of  rising  from  the  recumbent  position. 
The  peculiar  enlargement  of  the  muscles  of  the  calf  and  infraspi- 
natus, the  atrophy  of  the  latissimus  dorsi  and  lower  part  of  the 
pectoralis,  and  the  immunity  of  the  intrinsic  muscles  of  the  hand 
are  characteristic.  In  the  stage  of  contracture,  this  disease  differs 
from  congenital  spastic  paraplegia  in  that  there  is  no  increase  of 
deep  reflexes. 

Prognosis. — The  prognosis  in  children  is  grave.  The  affection  is 
progressive. 

Treatment. — Much  can  be  done  for  the  patients  by  means  of  mas- 
sage and  electricity.  In  the  stage  of  contractures,  while  there  is  still 
power,  relief  can  be  secured  by  tenotomy. 


876  DISEASES  OF  THE  NEBFOUS  SYSTEM. 

IDIOCY. 

Idiocy  is  not  of  itself  descriptive  of  any  one  disease  or  condition. 
It  is  a  generic  term  and  the  snbject  of  idiocy  is  considered  here  for 
the  sake  of  completeness  and  also  to  impress  npon  the  physician  cer- 
tain points  which  will  be  of  valne  to  him  in  his  daily  work.  Ireland 
defines  "  idiocy  as  a  mental  deficiency  or  extreme  stnpidity,  the  resnlt 
of  some  disease  or  malnutrition  of  the  nervous  centers.  It  occurs 
before  birth  or  before  the  evolution  of  the  mental  faculties  in  child- 
hood." From  this  definition  it  will  be  seen  that  there  are  forms  of 
idiocy  which  are  not  included  here,  such  as  the  juvenile  forms  of 
amaurotic  idiocy,  which  may  supervene  even  after  the  formation  of 
the  mental  faculties.  In  America  we  have  the  terms  mental  defects 
or  mental  backwardness  or  feeble-mindedness,  which  are  sometime^ 
used  in  a  humane  and  considerate  way  to  cover  certain  forms  of  mild 
idiocy  or  imbecility,  for  there  is  to  some  a  sense  of  offense  in  the  term 
idiocy ;  why  it  is  hard  to  say.  If  we  say  to  a  parent  that  a  child  is 
feeble-minded,  it  does  not  seem  to  strike  as  harshly  on  the  sensibilities 
as  when  the  crude  term  idiocy  is  used. 

Frequency. — Idiocy  is  quite  a  frequent  condition  in  America, 
though  it  is  a  very  difficult  matter  to  decide  as  to  the  comparative 
frequency  because  in  all  countries  parents  and  even  physicians  are 
loath  to  characterize  children  in  this  way  and  thus  in  a  general  census, 
on  account  of  this  partial  concealment,  only  inaccurate  data  can  be 
obtained.  According  to  Ternald  (1884)  one  in  every  500  individ- 
uals in  the  United  States  is  feeble-minded ;  in  England  and  Wales, 
one  in  771;  in  France,  one  in  1028;  and  in  Prussia,  one  in  730. 
This  is  quoted  only  for  the  purpose  of  showing  how  frequent  the  con- 
dition really  is  and  that  it  can  be  scarcely  ignored. 

Etiology.  ^ — The  etiology  of  idiocy  is  certainly  varied  and  differs 
very  much  as  to  the  form  under  consideration.  Thus  there  are  some 
forms  which  are  acquired  after  birth,  such  as  those  which  follow  an 
encephalitis,  infectious  diseases,  or  a  meningitis.  Their  etiology  is 
well-defined  and  is  that  of  the  original  disease.  On  the  other  hand 
there  are  forms  of  idiocy,  such  as  the  Mongolian  or  the  amaurotic,  the 
causation  of  which  is  still  obscure.  The  predisposing  causes  also  are 
rather  uncertain.  It  is  found  that  20  to  50  per  cent,  of  idiocy  occnrs 
in  families  of  neurotic  tendencies  and  in  consanguineous  marriages. 
This  does  not  dispose  of  the  subject,  for  it  does  not  tell  the  direction 
in  which  these  neurotic  tendencies  eventually  tend  to  the  ])r<)du('tion 
of  idiocy.  Intemperance  in  the  use  of  alcohol  in  the  parents  is  said 
to  tend  to  the  increase  of  the  prevalence  of  idiocy ;  a  contention  which 
is  not  susceptible  of  direct  proof.  Care  and  worry  on  the  ])art  of  the 
mother  during  pregnancy  undoubtedly  may  be  so  severe  as  to  react 
against  the  foetus.     I  have  seen  a  nnndier  of  examples  of  genetous 


IDIOCY.  877 

idiocy  in  which  there  was  a  distinct  history  of  fright  or  morbid  de- 
pression on  the  part  of  the  mother  during  pregnancy. 

Classification, — As  onr  clinical  and  experimental  knowledge  ad- 
vances the  classification  of  the  various  forms  of  idiocy  must  neces- 
sarily change. 

1.  Genetous  Idiocy. — This  term  was  introduced  by  Ireland  to 
include  all  those  cases  which  are  congenital,  that  is,  born  with  idiocy 
and  in  whom  the  cause  is  obscure.  Such  would  be  the  Mongolian 
idiocy  or  amaurotic  idiocy,  both  fully  treated  of  elsewhere. 

2.  Microceplinlic  Form. — This  form  of  idiocy  is  just  as  much  of 
obscure  origin  and  might  be  classed  as  a  form  of  congenital  idiocy 
with  lack  of  cerebral  and  cranial  development.  Some  of  these  cases 
at  the  age  of  eleven  and  twelve  years  have  been  found  to  have  a  head 
circumference  of  l-i-J  inches  and  1^\  inches  respectively.  Some  of 
my  own  cases  have  shown  not  only  a  small  head  circumference  for 
the  age,  but  other  marks  of  degeneration. 

There  are  various  degrees  of  microcephalus,  from  the  extremely 
small  head  to  the  head  which  almost  equals  the  normal  in  its  circum- 
ference. Other  dimensions  of  the  head  in  these  microcephalic  idiots 
are  also  smaller  than  normal,  thus  tending  to  contract  as  a  whole  the 
cranial  cavity.  Taking  six  of  my  own  cases,  the  following  measure- 
ments were  obtained  at  5  and  6  months :  a  head  circumference  in  two 
patients  of  374^  centimetres  and  33  centimetres  respectively;  a  third 
case  of  extreme  microcephalus  measured  V?i\  centimetres  in  circum- 
ference. An  infant  13  months  old  had  a  cranial  circumference  of 
32|  cm. ;  another  of  2  years,  44  centimetres ;  and  a  sixth  case  of  2 
years,  43  centimetres.  In  the  case  of  extreme  microcephalus  the 
anterior  fontanelle  was  closed;  in  the  less  marked  forms  of  micro- 
cephalus the  fontanelle  may  be  found  widely  open.  It  is  thus  not 
true  that  the  closure  of  the  anterior  fontanelle  determines  the  size  of 
the  brain  or  skull  in  these  cases. 

With  all  forms  of  microcephalus  there  are  other  evidences  of  irre- 
parable change  in  the  cerebral  substance,  such  as  spasticity  or  paral- 
ysis of  the  extremities  or  convulsions  later  on  in  childhood,  or  blind- 
ness and  deafness,  and  total  lack  of  intelligence  except  of  the  most 
animal  type  and  that  of  the  lowest  form  of  animal  life.  The  growth 
of  the  skull  is  very  slow^ ;  thus  in  one  case  at  the  age  of  2  months  the 
skull  measured  34|  cm.,  and  at  the  age  of  12  months  394^  cm.  In 
another  case  in  which  lambdectomy  had  been  performed  the  skull 
had  grown  only  5  cm.  in  a  year  and  a  half.  The  shape  of  the  head 
in  all  microcephalics  is  pyramidal  in  form,  the  forehead  very  low  and 
narrow. 

The  operation  of  lambdectomy  first  advocated  by  Lannelongue 
has  not  proved  of  any  avail  in  these  cases,  as  the  whole  operation  was 


878  DISEASES  OF  THE  NEBVOUS  SYSTEM. 

founded  on  the  theory  that  the  smallness  of  the  head,  and  therefore 
the  brain,  was  dne  to  a  premature  closure  of  the  anterior  fontanelle 
and  the  sagittal  suture.  I  have  repeatedly  demonstrated  that  in  some 
typical  microcephalics  the  fontanelle  was  widely  open,  so  that  the 
smallness  of  the  skull  can  be  hardly  traceable  to  the  above  once  widely 
accepted  theory  of  premature  closure  of  suture  or  fontanelle. 

3.  Hydrocephalic  Form. — The  hydrocephalic  form  of  idiocy  may 
be  congenital  or  acquired.  Both  forms  are  fully  discussed  elsewhere, 
both  under  the  heading  of  congenital  hydrocephalus  and  meningitis, 
where  the  acquired  form  of  hydrocephalus  is  fully  described. 

4.  Epileptic  and  Paralytic  Forms. — The  epileptic  and  paralytic 
forms  of  idiocy  are  fully  considered  in  the  chapter  devoted  to  the 
various  forms  of  cerebral  palsy,  as  are  also  those  forms  of  idiocy  which 
are  the  result  of  an  inflammatory  condition.  The  latter  are  treated 
of  in  the  chajoter  on  Encephalitis. 

5.  Cretinic  Form. — The  cretinic  form  of  idiocy  is  one  of  the 
forms  whose  etiology  has  been  greatly  cleared  by  experimental  path- 
ology and  its  characteristics  are  considered  elsewhere. 

6.  Sclerotic  and  Syphilitic  Forms. — The  sclerotic  and  the  syph- 
ilitic forms  of  idiocy  are  not  as  clearly  defined  as  some  of  the  other 
forms. 

Symptoms. — We  can  scarcely  speak  of  the  symptoms  of  idiocy,  a 
mental  state  which  is  in  itself  a  symptom  of  a  condition  of  the  ner- 
vous system.  All  idiotic  children,  however,  have  certain  well-defined 
characteristics.  Anatomically  the  facies  in  most  all  the  forms  are 
easily  recognizable.  The  Mongolian  idiot,  the  cretinic  idiot,  the 
microcephalic  idiot,  show  in  a  glance  facies  which,  when  once  seen, 
are  not  easily  forgotten.  This  is  not  so  of  some  of  the  milder  forms 
of  mental  backwardness  which  follow  either  intra-uterine  or  post- 
natal encephalitis.  In  such  cases  the  children  may  have  an  almost 
normal  appearance.  It  is  only  after  close  study  that  some  mental 
defect  is  discovered.  The  physician  must  therefore  defer  judgment 
in  all  doubtful  cases. 

This  is  especially  to  be  emphasized,  as  some  of  these  children  can- 
not be  called  idiots  in  the  full  sense,  but  are  rather  mental  defectives 
of  a  high  grade.  Some  of  these  forms  of  idiocy  are  useful  members 
of  society.  I  have  seen  a  blind,  genetous.  microcephalic  idiot  who 
was  a  most  excellent  interpreter  of  Wagnerian  music  and  whose  con- 
versational powers  were  undoubted,  but  who  nevertheless  was  a  mental 
defective.  Some  idiots  have  a  violent  temper;  others  are  mild  and 
docile.  Some  can  be  taught  to  be  self-supporting;  others  must  be 
cared  for.  The  high  palatal  vault  has  been  brought  forward  as  a 
characteristic  trait,  but  it  is  only  one  of  the  anatomical  peculiarities 
of  idiots  which  is  occasionally  seen  in  normal  individuals.     Deformi- 


DEFOEMITIES  OF  SKULL  AND  SPINAL  CANAL. 


879 


ties  of  the  extremities,  blindness,  deafness,  rumination,  and  slovering 
all  occur  in  the  various  forms  of  idiocy.  As  a  direct  result  of  mal- 
nutrition fully  two-thirds  of  all  idiots  are  tuberculous  or  scrofulous. 

Treatment  or  Management. — The  management  of  mental  defectives 
of  all  grades  is,  strange  to  say,  a  study  of  recent  times.  In  large 
cities,  such  as  ISTew  York,  the  care  of  the  higher  grade  of  mental 
defectives  is  but  just  receiving  the  public  attention  it  deserves.  It 
is  all  a  matter  of  careful  classification  and  education.  In  forms  of 
idiocy  or  mental  obscurity  in  which  therapy  is  of  avail,  as  in  cretin- 
ism, the  subject  has  received  attention  elsewhere. 

The  operative  treatment  of  microcephalic  and  hj'drocephalic  forms 
of  idiocy  has  been  fully  noticed.  The  marked  encephalitic  forms 
are  past  remedy  and  the  epileptic  or  eclamptic  and  Mongoloid  forms 
must  be  cared  for  in  separate  asylums  or  institutions,  where  special 
methods  and  attendants  are  at  hand. 

DEFORMITIES   OF   THE    SKULL  AND    SPINAL    CANAL. 

These  deformities  do  not  strictly  belong  to  the  disease  of  infancy 
and  childhood.  Only  the  forms  most  commonly  met  are  here  con- 
sidered. 

Fig.  202. 


Cranioscliisis.  Deficiency  of  the  frontal,  parietal,  and  most  of  the  occipital  bones. 
Protrusion  of  the  cranial  contents  in  shape  of  a  sac  covered  by  hair  and  scalp,  and 
containing  fluid  and  brain  substance.     Blindness  ;  idiocy. 


The  faulty  closure  of  the  spinal  canal  causes  a  deformity  called 
rachischisis  or  spina  bifida.     If  the  defect  involves  the  spinal  canal 


880  DISEASES  OF  THE  XEEVOVS  SYSTEM. 

in  its  whole  extent,  there  is  rachischisis  totalis.  The  vertebra  form 
a  shallow  canal  in  which  lies  the  rudimentary  spinal  cord  covered 
with  a  thin  membrane.  If  the  defect  of  the  bony  canal  is  only  par- 
tial, there  being  a  sac-like  protrusion  of  the  cord  and  its  membrane, 
there  is  said  to  be  a  rachischisis  cystica  or  spina  bifida  cystica  or 
rachicele. 

Faulty  development  of  the  cranial  bones  with  rudimentary  brain 
is  called  cranioschisis  (Fig.  202),  If  with  the  cranial  defects  there 
are  defects  of  the  bony  vertebral  canal,  there  is  said  to  be  cranio- 
raehischisis. 

If  there  are  only  partial  defects  in  the  cranial  bones,  with  saccu- 
lated protrusion  of  the  membranes  of  the  brain  (pia  and  arachnoid), 
with  fluid  in  the  sac,  there  is  a  meningocele.  Meningo-encephalocele 
is  a  sac  containing  in  addition  the  brain-substance,  Encephalocele 
is  a  hernia  of  the  brain  and  pia,  no  fluid  being  present  in  the  sac. 

Spina  Bifida. — Spina  bifida  or  hydrorrhachis  is  a  congenital 
deficiency  in  the  vertebral  lamina?,  through  which  the  cord  and  its 
membranes  protrude  in  the  form  of  a  sac  containing  fluid.  The 
deformity  is  most  frequently  seen  in  the  dorsolumbar.  dorsosacral, 
and  cervical  portions  of  the  vertebral  canal.  It  rarely  occttrs  in  the 
middorsal  region.  It  is  generally  single.  It  may  occtir  both  in  the 
neck  and  in  the  lumbar  region. 

The  tumor  may  be  small  and  only  indicated  by  a  fissure,  or  may, 
as  in  Broca's  case,  attain  a  circumference  of  62  cm.  It  may  be  flat 
or  pedunctilated.  The  latter  form  is  uncommon.  The  surface  of 
the  tumor  may  l^e  smooth  or  lobulated  and  uneven.  The  lobulated 
forms  indicate  divisions  in  the  interior  of  the  sac.  The  skin  cover- 
ing the  sac  may  be  very  thin  or  glistening.  It  may  burst  during 
delivery,  may  be  thick  and  vascular,  or  covered  with  cicatrices  and 
granulating  ulcers.  In  some  tumors  the  sulx-utaneous  tissue  can  be 
made  out;  in  others  the  skin  is  atrophic.  In  rare  cases  the  tumor  is 
composed  of  a  mass  of  mucous  tissue  situated  between  the  skin  and 
dura  mater.  In  the  interior  of  this  mass  there  is  a  small  cavity 
(Kirmisson),  Von  Recklinghausen  and  Mtiscatello  have  demon- 
strated that  the  statement  that  the  sac  of  the  spina  bifida  is  lined  with 
dura  mater  is  incorrect.  Hildebrandt  has,  however,  found  cases  in 
which  the  dura  lined  the  sac.  The  pia  and  arachnoid  line  the  sac. 
The  fluid  in  the  sac  is  serous  and  colorless  or  lemon-colored.  It  is 
alkaline  in  reaction,  rich  in  salts,  and  contains  sugar.  If  inflam- 
mation is  present,  blood  is  found  in  the  sac.  The  fluid  is  either  out- 
side thf  r-ord  or  in  the  central  canal  (Virchow). 

Classification. — Spina  bifida  is.  with  reference  to  the  nature  of  the 
contents  of  the  sac,  divided  into  three  forms : 

(a)  Myelomeningocele,  in  which  the  fluid  in  the  >ac  is  situated 
between  the  cord  and  its  membranes. 


DEFOEMITIES  OF  SKULL  AND  SPINAL  CANAL.  881 

(&)  Meningocele  spinalis,  in  which  the  inner  surface  of  the  sac 
is  formed  bj  the  arachnoid  and  pia  mater. 

(c)  Myelocystocele,  in  which  the  fluid  is  situated  in  the  central 
canal  of  the  cord. 

Myelomeningocele. — The  myelomeningocele  forms  a  broad  but 
not  very  prominent  tumor,  which  may  be  found  in  the  lumbosacral, 
cervical,  thoracic,  or  sacral  regions.  At  its  base  the  tumor  is  red- 
dish, and  is  covered  with  fine,  long  hairs.  This  zone  is  from  1  to 
l-g-  cm.  broad.  In  the  centre  of  the  tumor  there  is  a  reddish-brown 
velvety  vascular  area,  the  remains  of  the  medullary  vascular  zone. 
The  sac  is  formed  of  arachnoid  and  pia  mater.  Its  interior  is  crossed 
by  nerve-trunks.  The  cord  is  drawn  outward  and  some  nerves  may 
arise  from  the  prolongations  of  the  cord.  Accordingly,  there  is  an 
accumulation  of  fluid  in  the  meninges  (hydromieningocele),  with  an 
accompanying  hernia  of  the  cord  (myelocele). 

Meningocele  Spinalis. — Meningocele  spinalis  is  the  rarest  form 
of  spina  bifida.  The  sac  is  composed  of  pia  and  arachnoid.  The 
latter  may  be  much  thickened.  The  opening  into  the  vertebral  canal 
if  large  may  allow  hernia  of  the  cord.  If  the  tumor  is  situated  in 
the  sacral  region,  the  interior  of  the  sac  may  contain  the  nerves  of 
Cauda  equina. 

Myelocystocele,  Hydromyelocele,  or  Syringomyelocele. — Myelo- 
cystocele, hydromyelocele,  or  syringomyelocele,  is  that  form  of  spina 
bifida  in  which  there  is  a  dilatation  of  the  central  canal  of  the  cord. 
The  dura  is  lacking  in  the  sac,  which  is  lined  with  cylindrical  epithe- 
lium. The  spinal  cord  in  part  of  its  extent  may  be  found  in  the  sac, 
or  may  be  found  on  the  exterior  wall  of  the  sac  and  end  there.  It 
may  break  up  into  several  bundles.  In  the  interior  the  spinal  nerves 
form  a  series  of  loops  with  their  convexities  posteriorly.  They  may 
return  into  the  vertebral  canal  or  may  end  in  the  sac.  Spina  bifida 
is  a  primary  agenesis.  The  growth  of  the  sac  is  due  to  inflamma- 
tory processes. 

Symptoms. — The  tumor  is  the  chief  physical  sign.  It  is  situated 
in  the  median  line  or  may  be  at  one  side.  It  is  round  or  elliptical 
and  covered  with  thinned  or  thickened  skin  (Fig.  203).  In  the 
centre  of  the  myelocystocele  is  a  depression  which  gives  the  tumor  a 
tomato-like  appearance.  The  tumor  may  be  soft,  hard,  or  fluctuating. 
The  defective  vertebral  laminse  may  be  discerned  on  palpation.  The 
tumor  enlarges  and  becomes  tense  when  the  patient  assumes  the 
upright  posture,  cries,  or  exerts  himself.  When  the  patient  takes 
the  recumbent  posture  it  becomes  smaller.  It  also  does  so  at  each 
inspiration. 

In  some  cases  the  functions  of  the  iiidividual  are  normal.  In 
others,   the  mobility  and  sensibility  of  the   lower   extremities   are 

56 


882 


DISEASES  OF  THE  NEEVOUS  SYSTEM. 


affected.  Deformities  of  the  foot  similar  to  those  seen  in  infantile 
paralysis  are  sometimes  present.  There  may  be  incontinence  of 
urine  and  faeces.  There  are  sometimes  trophic  disturbances,  such  as 
perforating  ulcers.  These  are  of  value  in  the  diagnosis  of  lumbar 
tumors  which  are  apparently  lipomatous  in  their  nature  and  are 
covered  with  hair  (Kirmisson).  In  such  tumors,  disturbances  of 
sensibility  occurring  with  perforating  ulcers  and  deformity  and 
atrophy  of  a  lower  extremity  are  significant  of  spina  bifida. 

Fig.  203. 


Spherical  form  of  spina  bifida  lumballs,  ulceration  at  superior  surface  of  tumor. 

Course. — Spina  bifida  if  left  to  itself  may  grow  to  a  large  size, 
may  burst  or  ulcerate,  and  cause  death  by  pyogenic  infection  of  the 
meninges  and  cord  tissue.  In  other  cases  a  lineal  ulcer  discharges 
fluid  and  closes  up  several  times  in  succession.  In  some  cases  of 
spina  bifida  the  tumors  remain  stationary  in  size  until  late  in  adult 
life.  In  rare  cases  spontaneous  cure  results  by  inflammation  of  the 
pedicle  of  a  pedunculated  spina  bifida. 

Diagnosis. — The  diagnosis  of  spina  bifida  is  not  ditfieult  if  what 
has  been  detailed  of  the  anatomy  and  symptomatology  is  borne  in 
mind.  Muscatello  gives  the  following  characteristics  of  the  various 
forms : 

Myelocystocele. — In  myelocystocele  there  is  a  rouud  tumor  with 
a  wide  base.  The  tumor  is  lumbosacral,  clastic,  translucent,  and 
fluctuating,  and  does  not  diminish  on  pressure.  Pressure  causes 
tenseness  of  the  fontanelle.  There  may  be  scoliosis,  lordosis,  abdom- 
inovesical  fissures,  and  deformity  of  the  foot. 

Myelomeningocele. — In  myelomeningocele  there  is  a  flat,  soft, 
elastic  tumor,  either  lumbar,  sacral,  cervical,  or  thoracic.  It  may 
be  complicated  by  umbilical  hernia,  paralysis  of  the  extremities  and 
bladder,  and  deformity  of  the  foot. 


DEFORMITIES  OF  SKULL  AND  SPINAL  CANAL. 


883 


Meningocele. — In  meiiiiigocele  there  is  a  sacral  pedunculated 
translucent  tumor,  but  no  disturbances  of  mobility  or  sensibility. 

Spina  Bifida  Occulta. — Of  considerable  interest  is  the  form  called 
spina  bifida  occulta  (Fig.  204).  In  these  cases  there  may  be  no 
tumor,  the  seat  of  the  deformity  being  indicated  by  a  depression  or 
dimple.  In  other  cases,  as  in  that  shown  in  the  illustration  from 
Kirmisson,  there  is  a  small  tumor  of  doughy  consistence  on  one  of 

Fig.  204. 


Spina   bifida   occulta. 


the  gluteal  folds.  The  tumor  may  present  an  umbilication.  Spina 
bifida  occulta  should  be  suspected  in  cases  in  which  abnormal  sacral 
depressions  or  tumors  occur  in  connection  with  clubfoot  deformities 
or  congenital  incontinence  of  urine  or  faeces,  or  of  both. 

Treatment. — The  treatment  of  spina  bifida  belongs  to  the  domain 
of  surgery.  The  treatment  by  injections  of  Morton's  fluid  (2  per 
cent,  of  iodine,  6  per  cent,  of  potassium  iodide  in  glycerin)  has  been 
abandoned  in  favor  of  excision  of  the  sac. 


SECTION  XYI. 

DISEASES  OF  THE  SKIN. 

The  skin  of  the  infant  is  exceedingly  delicate  in  structure.  After 
birth  there  is  a  physiological  condition  of  desquamation,  as  a  result 
of  which  the  skin  is  very  sensitive  to  a  traumatism  which  in  older 
children  would  be  considered  slight.  In  the  newly  born  infant,  such 
is  the  delicacy  of  the  structure  of  the  skin  that  infection  may  occur 
when  no  lesion  of  continuity  is  apparent  (cryptogenic).  A  rapid 
examination  of  the  skin  is  the  first  step  in  making  a  full  physical 
examination  of  an  infant  or  child.  The  surface  is  first  inspected 
from  a  distance,  the  color  and  the  presence  or  absence  of  an  eruption 
being  noted.  It  is  of  the  first  importance  to  decide  whether  an  erup- 
tion is  acute  or  connected  with  constitutional  taint  (syphilis).  An 
eczema  may  in  a  syphilitic  infant  have  certain  characteristic  varia- 
tions of  color  which  will  at  once  lead  the  examiner  to  suspect  consti- 
tutional disease.  A  familiarity  with  acute  eruptions  (exanthematic) 
is  essential.  These  must  be  diagnosed  or  excluded  before  any  treat- 
ment can  be  inaugurated.  Forms  of  oedema  must  be  differentiated 
from  sclerema  and  myxoedema,  and  indurations  of  the  skin  from  ele- 
vations. A  papule  may  be  elevated  but  not  indurated.  Since  the 
skin  of  infants  and  children  is  exceedingly  delicate,  it  will  show  indu- 
rations more  distinctly  than  that  of  the  adult. 

The  Care  of  the  Skin. — Stretching  or  harsh  manipulation  of  the 
skin  of  infants  will  tear  or  traumatize  it.  Irritating  soaps  should 
not  be  used.  The  drying  of  the  skin  should  be  carried  out  gently. 
The  skin  in  the  groin  and  axilla  should  not  be  unduly  stretched  lest 
rhagades  or  fissures  result.  In  powdering  the  skin,  a  fresh  pledget 
of  absorbent  cotton  should  be  used  as  a  powder  puff,  and  all  the  excess 
of  powder  blown  off,  lest  caking  result.  In  some  infants  the  wearing 
of  flannel  or  wool  next  to  the  skin  causes  irritation  and  eruptions  of 
different  varieties.  Such  infants  should  wear  a  very  fine  cambric 
or  linen  garment  next  the  skin,  and  over  this  the  woollen  shirt. 

ECZEMA. 

Eczema  is  a  very  common  affection  in  infancy  and  childhood. 

Some  infants,  otherwise  in  apparent  health,  suffer  at  times  from 
a  very  mild  eczema  of  the  face,  which  appears  chiefly  on  the  cheeks, 
but  which  may  also  be  present  on  the  chin,  forehead,  and  ears.     The 

884 


ECZEMA.  885 

infants  do  not  seem  to  suffer  much,  except  that  they  scratch  the  erup- 
tion. The  eruption  is  local.  It  may  improve  without  treatment, 
but  if  there  are  conditions  of  traumatism  and  infection,  it  will  grow 
worse.  It  is  rarely  moist,  but,  if  scratched,  it  will  bleed,  and  fissures 
or  ulcers  with  bloody  crusts  will  form. 

Another  form  of  eczema  is  pustular  and  vesicular.  The  skin  of 
the  face  has  a  red,  angry  look.  Here  and  there  patches  of  skin  are 
covered  with  scabs ;  in  other  areas  the  skin  is  moistened  by  a  serous 
or  seropurulent  exudate.  This  eczema  is  usually  also  present  on  the 
hands  and  arms.  If  the  malady  has  existed  any  length  of  time,  there 
is  considerable  thickening  of  the  skin  of  the  hands.  The  head  and 
scalp  may  be  affected. 

Eczema  is  sometimes  general.  On  the  face,  it  is  general  and  pus- 
tular; on  the  body,  there  are  both  the  squamous  and  the  pustular 
forms  with  all  the  various  gradations  between.  There  are  crusts, 
rhagades,  and  areas  of  superficial  loss  of  tissue. 

The  infants  scratch  and  are  uneasy  and  restless  at  night,  but  the 
general  health  is  excellent  and  the  appetite  and  digestion  are  good. 
The  weight  increases.  If  the  eczema  is  general,  the  infants  some- 
times become  puny.  They  scratch  the  eruption,  constantly  causing' 
the  surface  to  bleed.  The  body  is  sometimes  one  raw,  suppurating- 
surface.  The  lymph-nodes  connected  with  the  affected  surface  are 
enlarged.  Such  enlargements  should  be  differentiated  from  those  of 
pyogenic  origin. 

A  very  troublesome  form  of  eczema  is  the  impetiginous  or  pus- 
tular variety.  The  pustules  burst  and  leave  the  surface  covered  with 
dried  crusts  of  pus.  This  form  may  affect  any  part  of  the  body.  Of 
especial  interest,  and  in  a  class  apart,  is  the  so-called  impetigo  faciei 
contagiosa.  This  is  a  contagious  pustular  eczema.  It  affects  by 
predilection  the  upper  lip  and  the  alse  nasi.  The  pustules  break  down 
and  leave  dry  crusts  of  a  golden-yellow  color.  The  anterior  nare& 
may  be  blocked  up  by  these  crusts.  This  variety  of  impetigo  may 
in  children  spread  over  the  whole  surface  and  the  extremities.  I 
have  seen  it  affect  several  children  in  a  family.  There  can  be  very 
little  doubt  as  to  the  infectious  and  contagious  nature  of  the  malady. 
Eichstedt,  Lustgarten,  and  others  have,  with  cocci  obtained  from  the 
pustules,  succeeded  in  inoculating  the  malady  on  the  human  subject. 

Intertrigo  (eczema  intertrigo)  or  erythema  intertrigo  is  one  of 
the  forms  of  erythema  which  develop  by  maceration  into  an  eczema. 
Intertrigo  is  found  in  the  folds  of  the  neck,  axilla,  and  groin,  in 
well-nourished,  rather  obese  infants.  It  is  at  first  acute,  but  may 
become  chronic.  There  is  at  first  a  slight  redness  of  the  folds  of  the 
skin  (erythema).  If  through  neglect  the  epidermis  is  allowed  to 
macerate,   excess   of   secretion   results    and   the   collected   secretions 


886  DISEASES  OF  THE  SEIX. 

decompose;  tlie  surfaces  may  become  eroded,  and  ulcerations  result. 
In  some  cases  there  are  lineal  ulcers  in  the  groin.  In  others,  the 
ulcers  may  become  coated  with  a  pseudomembrane.  In  rare  cases 
actual  necrosis  of  tissue  results.  Some  anaemic  infants  present  a  ten- 
dency to  rhagade  formation,  not  only  in  the  groin,  but  also  around 
the  anus  and  lips.  The  intertrigo  may  have  the  color  of  copper, 
instead  of  the  bright-red  hue  of  an  ordinary  eczema.  In  such  cases 
there  is  always  a  possibility  that  the  intertrigo  may  be  of  syphilitic 
origin.  If  there  is  no  great  panniculus  of  fat,  and  if  with  the  inter- 
trigo there  appear  erythema  and  fissures  between  the  toes,  and  glossi- 
ness of  the  skin  on  the  plantar  surface  of  the  feet,  there  are  additional 
grounds  for  assuming  that  there  is  a  syphilitic  element.  Intertrigo, 
like  other  skin  eruptions,  may  be  accompanied  by  enlargement  of 
the  lymph-nodes  leading  from  the  region  affected.  In  obese  infants, 
the  umbilicus  may  also  be  the  seat  of  eczema,  which  results  from  the 
accumulation  and  decomposition  of  secretions. 

Seborrhoea  capillitii  is  an  eruption  on  the  scalp  of  infants  and 
children  which  is  classified  by  Unna  as  a  form  of  eczema.  The  scalp 
is  covered  with  a  coating  of  yellow  or  discolored  sebum,  which  con- 
sists of  fat,  desquamated  epithelium,  and  hair.  If  allowed  to  accu- 
mulate, it  is  sometimes  of  considerable  thickness  and  may  be  detached 
from  the  scalp.  It  then  leaves  a  slightly  reddened  surface,  which 
may  bleed.  In  a  short  time  the  scalp  may  become  glossy,  and  a  new 
layer  of  the  fatty  secretion  may  form.  This  process  may  continue 
until  the  second  or  third  year.  This  seborrhoeic  eczema  has  some- 
times a  cheesy  odor. 

Seborrhoea  of  the  umbilicus  has  been  mentioned.  In  infants  and 
children  there  may  also  be  seborrhoea  of  the  prepuce.  There  are,  in 
neglected  cases,  secretion  and  aphthous  ulcerations  of  the  folds  be- 
tween the  glans  and  the  prepuce  and  in  the  folds  of  the  prepuce. 

Of  great  interest  to  the  physician  is  a  form  of  intertrigo  or 
eczema  found  on  the  buttocks  and  between  the  nates  of  infants.  It 
occurs  in  infants  who  are  not  kept  dry  and  whose  urine  decomposes 
easily  if  the  diapers  are  not  changed  frequently.  This  is  a  most 
troublesome  form  of  eczema.  The  nates  are  at  first  red,  the  skin 
then  becomes  glossy  and  brittle,  and  there  may  be  extensive  desqua- 
mation of  the  surface.  This  form  of  eczema  or  intertrigo  may  dis- 
appear under  treatment,  only  to  return  if  precautions  as  to  cleanliness 
and  dryness  are  not  observed.  Some  of  the  children  suffer  from 
enuresis,  and  contract  the  affection  through  maceration  of  the  skin 
by  the  decomposed  urine,  or  from  unclean  diapers. 

Etiology, — The  etiology  of  eczema  is  still  obscure.  The  condi- 
tions in  infancy  and  childhood  are  favorable  to  the  development  of 
skin  affections.     The  delicacy  of  the  skin,  its  constant  exposure  to 


ECZEMA.  887 

dirt  and  to  irritants  of  all  kinds,  and  changes  of  temperature,  are 
etiologically  important.  All  the  children  of  a  family  may  suffer 
from  eczema.  In  such  instances,  there  is  a  real  hereditary  tendency 
to  the  disease.  The  parents  are  sometimes  similarly  affected.  The 
influence  of  diet  in  causing  eczema  is  not  yet  understood,  but  some 
authors  are  firmly  convinced  of  the  deleterious  effects  of  certain  arti- 
cles of  food.  I  have  known  urticaria  to  be  caused  by  eating  oatmeal 
and  fruits,  such  as  strawberries,  and  urticaria  may  be  the  beginning 
of  eczema.  In  most  cases  eczema  cannot  be  attributed  to  articles  of 
diet.  It  is  possible  that  in  certain  children  the  processes  of  metabo- 
lism are  at  fault.  Though  it  has  not  been  proved  that  all  eczema  is 
of  an  infectious  character,  there  can  be  but  little  doubt  that  many 
forms  are  caused  by  the  deleterious  action  of  micro-organisms  on  the 
skin  (Unna).  In  favor  of  this  theory  is  the  fact  that  in  many  para- 
sitic skin  affections  eczema  is  an  accompanying  condition. 

Treatment. — The  treatment  of  eczema  is  exceedingly  difficult. 
The  external  causes  of  irritation  should  be  immediately  removed. 
Attention  to  cleanliness  is  alone  sometimes  sufficient  to  cure  an  eczema. 
If  woollen  clothing  is  irritating  to  the  skin,  a  substitute  should  be 
found  and  cotton  or  cambric  should  be  worn  underneath  the  wool. 

The  diet  should  be  regulated.  This  is  not  an  easy  task,  since  it 
is  not  known  what  articles  of  diet  produce  eczema.  If  the  infant  is 
at  the  breast,  the  diet  of  the  wet-nurse  and  her  daily  habits  should  be 
regulated.  Even  when  the  nurse  takes  simple  food,  and  the  milk  is 
flawless,  the  infant  may  suffer  from  eczema.  If  the  nurse  is  addicted 
to  the  use  of  beer,  or  vegetables,  such  as  asparagus,  the  quality  of  the 
milk  may  be  affected.  The  diet  of  a  wet-nurse  should  not  be  changed 
more  often  than  is  necessary,  else  the  secretion  of  milk  may  cease. 
If  the  wet-nurse  has  a  rheumatic  or  gouty  tendency,  it  is  wise  to 
change  nurses.  On  the  other  hand,  an  infant  may  be  overfed  and 
excessively  fat.  In  that  case  the  intervals  between  nursings  should 
be  lengthened.  To  attempt  to  change  the  percentage  of  fat  in  the 
milk  is  not  only  of  questionable  utility,  but  is  not  always  feasible. 
If  the  nurse  is  constipated,  the  bowels  should  be  regulated,  and  she 
should  take  abundant  exercise.  Artificially  fed  infants  are  still  more 
difficult  to  manage.  If  the  infant  is  thriving,  interference  with  the 
food  percentage  is  not  always  clearly  indicated.  Artificially  fed 
infants  may  also  be  overfed  or  the  percentage  of  fat  or  proteids  may 
be  too  high.  There  may,  however,  be  eczema  even  when  the  compo- 
sition of  milk  is  proper  for  the  infant,  age  and  weight  being  taken 
into  consideration. 

If  there  are  acidity  of  the  stomach,  excessive  flatus,  constipation, 
or  green  stools,  regulation  of  diet  is  of  more  practical  utility.  In 
such  cases  it  may  cause  the  eczema  to  diminish.     If  there  is  stomach 


888  DISEASES  OF  TEE  SKIN. 

acidity,  an  alkali  (lime-water)  should  be  added  to  the  food.  Con- 
stipation and  flatulence  should  be  remedied.  If  the  infant  passes 
urine  with  urates  to  such  an  extent  as  to  cause  a  red  deposit  on  the 
diaper,  small  doses  of  bicarbonate  of  sodium  should  be  administered 
and  lime-water  should  be  mixed  with  the  food. 

Changes  of  diet  are  helpful  only  in  those  forms  of  eczema  which 
are  either  general  or  disseminated  over  different  parts  of  the  surface. 
Seborrhoea  and  intertrigo  are  purely  local  affections,  and  are  not 
influenced  by  changes  of  diet. 

Local  treatment  is  chiefly  relied  upon  to  improve  the  condition 
of  the  skin.  In  the  acute  or  subacute  forms  soothing  applications 
are  utilized.  The  chronic  forms  are  irritated  into  a  state  of  reaction, 
and  then  treated  like  acute  eczema.  The  treatment  of  acute  local 
eruptions,  such  as  intertrigo,  consists  first  in  kee23ing  the  parts  scru- 
pulously clean.  After  the  bath  the  folds  of  the  skin  are  mopped, 
dried  carefully,  and  powdered,  the  excess  of  powder  being  blown  off. 
This  alone  is  sometimes  sufficient  to  cure  a  slight  intertrigo.  Dusting- 
powders  which  contain  carbolized  preparations  irritate  the  skin.  A 
good  powder  has  the  following  composition : 

5:     Zinci  oxidi 3iv  (16.0). 

Amylum 3ij  (60.0).— M. 

Equal  parts  of  zinc  and  starch  powder  make  an  equally  good  powder. 
These  ingredients  should  be  ground  to  an  impalpable  powder.  In 
the  severer  forms  of  intertrigo,  the  parts  should  first  be  anointed  with 
ointment  having  the  following  composition : 

^     Eesorcin .     gr.  ij-iv  (0.12-0.24). 

Adeps   benzoinati 5J  (30.0). 

M. — The  lard  should  be  washed. 

The  ointment  should  be  removed  from  the  folds  of  the  skin  with 
a  pledget  of  lint.  The  skin  after  being  thus  left  in  a  slightly  greasy 
state  is  powdered,  the  excess  of  powder  being  blown  off.  If  there 
are  lineal  ulcers  in  the  groin,  they  should  be  lightly  touched  once 
a  day  with  a  2  per  cent,  solution  of  nitrate  of  silver,  to  promote 
granulation.  The  ointment  should  then  be  applied  with  a  small  piece 
of  lint. 

In  squamous  eczema  which  is  a  red  or  pustular  eczema  of  the  face, 
scalp,  and  hands,  the  first  question  that  arises  is  whether  the  patients 
should  be  bathed.  An  infant  should  be  kept  clean,  and  there  is  only 
one  satisfactory  method,  and  that  is  the  bath.  If  there  is  eczema  of 
any  part  of  the  surface,  the  bath  water  may  be  liberally  impregnated 
with  bran.  A  gauze  bag  filled  with  a  measure  of  bran  is  put  into 
the  bath  and  the  bag  is  squeezed  until  the  water  becomes  turbid.  If 
a  minute  quantity  of  bicarbonate  of  sodium  is  added  to  a  bath  pre- 


ECZEMA.  889 

pared  in  this  way,  tlie  effect  on  general  eczema  is  decidedly  soothing. 
The  skin  is  gently  dried  after  the  bath  and  powdered.  If  the  whole 
trunk  is  involved,  it  is  best  that  the  parts  of  the  surface  should  be 
treated  in  succession.  The  face  or  an  arm  is  covered  with  an  oint- 
ment applied  by  means  of  a  piece  of  lint,  or  the  ointment  is  simply 
rubbed  on  the  skin  after  the  bath.  It  is  not  feasible  to  wrap  the 
whole  body  in  lint  and  dintment ;  with  certain  drugs,  such  as  resorcin, 
absorption  would  occur.  The  ointm-ents  should  be  applied  after  the 
crusts  and  pustular  accumulations  have  been  removed.  All  oint- 
ments should  be  made  up  with  washed  benzoinated  lard.  Vaseline 
is  very  irritating  to  some  forms  of  eczema.  Of  the  emollient  and 
soothing  ointments,  diachylon,  zinc,  and  bismuth  hold  a  leading  place. 
A  very  good  ointment  for  general  use  in  rhagades  and  squamous 
eczema  is  the  following,  which  is  one  of  Kaposi's  formulae : 

K  Resin,  benzoea  pulv jj  (4.0). 

_  Axung.porc gv  (150.0). 

Digere  cola  adde. 

Zinc,  oxidat gj  (30.0). 

M.  et  ft.  unguentum. 

If  made  up  properly,  this  is  an  excellent  cosmetic  ointment  for  use 
in  dry  eczema.     If  the  skin  is  dry  and  thickened,  a   1  per  cent, 
/ff-naphthol  applied  twice  daily  will  soften  it.     If  this  treatment  proves 
irritating,  a  zinc  ointment  may  be  applied  immediately  afterward. 
In  many  cases  of  chronic  eczema  Lassar's  paste  is  beneficial : 

K  Acidisalioyl gr.  xxx   (2.0). 

Zinci  oxidat. ")  --  -•   /QAn^ 

.        1  > ««  .^1   (oU.U). 

Amylum         /  oj   \        j 

Vaselin ' §jss  (45.0). 

M.  et  ft.  paste. 

The  following  ointment  is  also  excellent : 

R  Acidi  salicylici gr.  xv  (1.0). 

Ung.  zinci  oxidi gij  (60.0). — M. 

The  tar  salves  and  mixtures  are  useful  in  cases  of  chronic  eczema 
in  which  there  is  little  or  no  moisture : 

K  01.  rusci 3i  (4.0). 

Ungt.  zinci  ox 3J   (30.0). 

M. — For  external  use. 


or 


R  01.  fagi ^ijss  (10.0). 

Glycerin ;5J   (4.0). 

Ung.  diachylon |jss  (45.0). 

Balsam.  Peru 1^  xxx  (2.0).— M. 


890  DISEASES  OF  THE  SKIN. 

In  eases  of  red  eczema  of  the  face,  the  ointment  is  best  applied 
on  a  mask  made  of  lint. 

In  that  form  of  intertrigo  which  resnlts  from  the  irritation  of 
urine,  the  condition  of  the  diaper  is  frequently  the  chief  source  of 
trouble.  It  is  often  damp  or  too  thin.  As  a  result,  whenever  the 
infant  passes  urine,  the  diaper  becomes  saturated  with  it  and  decom- 
position takes  place.  A  piece  of  absorbent  gauze  as  large  as  the 
diaper  should  be  placed  next  the  skin,  and  renewed  whenever  it 
becomes  moistened.  The  skin  is  dried  and  the  ointment  applied  on 
the  gauze.     Intertrigo  is  quickly  cured  by  this  treatment. 

Treatment  of  Seborrhcea  of  the  Scalp. — The  accumulated  sebum  is 
moistened  with  oil,  or  a  piece  of  lint  moistened  with  olive  oil  or  any 
indifferent  oil  is  applied  at  night.  In  the  morning  the  crust  of  sebum 
will  have  softened  sufficiently  to  allow  of  its  removal  with  gTeen  soap 
and  water.  After  the  parts  are  well  cleaned,  a  salicylated  ointment, 
0.5  to  1  per  cent.,  is  applied  daily.  The  ointment  should  be  spar- 
ingly applied  in  order  that  it  may  not  irritate  the  parts.  Seborrhoea 
should  be  treated  for  some  time  after  it  is  apparently  cured,  or  it  will 
return.  In  older  children  who  have  abundant  hair,  the  seborrhcea 
accumulates  at  the  roots  and  the  scalp  has  an  odor.  The  head  should 
be  thoroughly  shampooed  once  a  week ;  after  the  shampoo,  an  exceed- 
ingly small  quantity  of  cosmetic  hair  oil  should  be  applied  to  the  scalp 
once  a  day. 

ERYTHEMA  MULTIFORME. 

{Erythema  Nodosum;  Erythema  Exudativum.) 

Erj'thema  exudativum  is  divided  into  two  forms.  The  acute 
form  includes  erythema  multiforme  and  nodosum,  and  is  an  acute 
infectious  disease  (Lewin).  The  exudative  form  occurs  frequently 
in  infants  and  children.  Of  40  of  my  cases,  10  were  under  two 
years  of  age. 

The  form  of  erythema  known  as  erythema  nodosum  begins  with 
general  malaise  and  sometimes  with  fever,  which  may  be  quite  high. 
There  is  pain  in  the  joints  and  over  the  areas  affected.  These  areas 
are  raised  and  are  purple  or  bluish;  the  skin  is  tense  and  the  parts 
affected  are  very  painful.  The  nodes  vary  in  size.  They  first  appear 
chiefly  on  the  extensor  surface  of  the  tibi^.  The  extremity  some- 
times looks  as  if  it  had  been  beaten.  This  form  of  erythema  is  per- 
haps allied  to  hemorrhagic  diseases,  such  as  peliosis.  In  a  case  of 
pcliosis  rheumatica  which  I  saw  recently  there  were  erythematous 
and  painful  nodules  on  the  hands.  Antitoxin  may  cause  exudative 
erythema.  As  is  well  known,  such  toxic  infection  also  involves  the 
joints.     The  symptoms  are  fever,  pain  in  the  joints,  and  extensive 


FUEUNCULOSIS.  891 

erythema  nodosum.  I  have  seen  such  a  case  in  a  subject,  who  had 
received  an  immunizing  injection.  Within  six  hours,  the  legs,  knees, 
and  thighs  were  swollen  and  the  seat  of  this  peculiar  erythema. 

French  writers  speak  of  the  frequency  of  cardiac  disease  in  ery- 
thema nodosum,  and  of  its  relationship  to  rheumatism.  I  have  care- 
fully studied  40  cases  for  signs  of  cardiac  disease,  and  could  find 
only  3  cases  with  systolic  murmur  at  the  apex.  I  have  recently  seen 
2  others.  In  my  opinion,  true  endocarditis  is  not  a  very  common 
complication  of  erythema  nodosum.  In  only  one  case  did  the  mur- 
murs appear  to  be  serious.  The  disease  lasts  only  a  few  days,  but 
there  may  be  relapses. 

The  second  form  of  chronic  erythema  resembles  the  acute  form. 
The  nodules  are  flat  and  deep,  and  are  not  raised  much  above  the 
surface.  They  appear  chiefly  on  the  lower  extremities  of  badly  nour- 
ished children.  They  are  less  painful  than  in  the  acute  form.  After 
a  time  they  disappear,  leaving  no  sign  of  their  presence. 

Treatment. — Cases  of  erythema  of  the  acute  form  are  treated  with 
sodium  salicylate  and  a  diet  of  milk  at  first,  fruit-juices  and  beef- 
juice  being  given  later,  and  local  applications  of  oil  of  wintergreen 
to  the  painful  areas. 

FURUNCULOSIS. 

{Folliculitis  Abscedens  or  Perifolliculitis  Ahscedens. — Escherich.) 

.  This  affection  of  the  skin  is  very  common  in  infancy  and  child- 
hood, and  occurs  chiefiy  in  badly  nourished,  marantic  babies,  who 
suffer  from  gastro-enteric  and  pulmonary  infections.  The  disease  is 
due  to  an  invasion  of  the  deeper  layers  of  the  skin  by  staphylococci. 
These  have  been  found  in  the  pus  and  in  the  sweat  and  sebaceous 
glands  of  the  skin  (Escherich).  In  the  mild  forms  of  furunculosis 
there  are  one,  two,  or  more  furuncles  on  the  forehead,  scalp,  occiput, 
and  neck.  Sometimes  the  furuncles  are  large  and  the  skin  is  riddled 
with  them,  but  as  a  rule  they  do  not  communicate  with  one  another. 
In  aggravated  cases,  furuncular  abscesses  occur  on  the  trunk  and  on 
the  upper  and  lower  extremities.  When  the  furuncles  or  boils  be- 
come very  numerous,  they  play  a  leading  role.  Many  children  in 
institutions  succumb  to  this  affection.  The  condition  closely  resem- 
bles a  form  of  sepsis. 

Treatment. — The  treatment  of  these  cases  is  simple.  I  have  ad- 
ministered alkalies,  such  as  bicarbonate  of  sodium,  internally.  The 
effect  on  the  general  process  is  excellent.  I  have  also  given  sulphide 
of  calcium  in  grain  -J  doses  (0.03)  with  good  effect.  The  infant  is 
bathed  in  bran  daily.  Too  many  of  tjie  abscesses  should  not  be 
opened  at  once,  and  they  should  not  be  opened  until  they  point  and 


892  DISEASES  OF  TEE  SKIN. 

the  skin  over  them  becomes  reddened.  If  thej  are  opened  earlier, 
the  results  are  not  so  good.  After  the  abscesses  are  opened,  the  pns  is 
expressed  and  a  moist  dressing  applied.  The  abscesses  heal  easily. 
As  in  other  septic  affections,  the  patients  should  be  stimulated  and 
carefully  fed.  Small  furuncles  appearing  only  on  the  face  need  not 
be  opened.  The  application  of  a  2  per  cent,  salicylated  ointment 
twice  daily  softens  the  pustules  and  causes  the  contents  to  be  dis- 
charged. I  have  seen  most  brilliant  results  from  the  use  of  vaccines 
in  cases  above  described.  The  vaccines  should  be  prepared  from  the 
pus  of  the  furuncle  or  abscess. 

SUDAMINA. 

(Miliaria  Alba;  Miliaria  Buhra.) 

Sudamina  is  an  affection  occurring  in  infants  and  children  during 
very  warm  weather.  In  the  form  called  miliaria  alba  the  epidermis 
at  the  openings  of  the  sweat-glands  is  raised  by  a  minute  serous  exu- 
date and  small  vesicles  are  formed.  There  is  no  inflammation  of 
the  skin.  In  a  second  form,  the  same  process  takes  place,  with  the 
presence  of  a  minute  focus  of  inflammation  and  redness  at  the  open- 
ing of  the  glands.  Some  of  the  vesicles  are  pustular.  There  are 
also  numerous  papules  of  eczema.  There  is  a  slight  infection  of  the 
skin  about  the  opening  of  the  sweat-glands.  Both  these  conditions 
are  irritating,  but  in  no  way  serious.  The  skin  should  be  kept  scru- 
pulously clean  and  dried  with  powder.  Woollen  fabrics  should  not 
be  worn  next  the  skin.  If  the  condition  becomes  severe,  bran  baths 
and  a  bland  zinc  or  diachylon  ointment  should  be  used.  Sudamina 
of  both  varieties  are  met  with  in  scarlet  fever  dermatitis. 

DERMATITIS  EXFOLIATIVA. 

(ElTTER  VON   ElTTERSHAIN.) 

This  affection  is  peculiar  to  the  newborn  infant.  Eitter  in  1878 
described  an  epidemic.  In  1895  Escherich  published  an  account  of 
a  small  outbreak  in  Gratz. 

Nature  and  Etiology. — It  was  first  suspected  by  Hitter  to  be  one  of 
the  septic  infections  of  the  newly  born  infant.  His  view  has  lately 
been  supported  by  Escherich. 

Occurrence  and  Symptoms. — The  disease  appears  from  a  few  days 
to  two  weeks  after  birth.  It  usually  occurs  in  poorly  nourished  in- 
fants, but  may  affect  apparently  healthy  infants  of  normal  weight. 
Boys  are  more  frequently  affected  than  girls.  The  affection  is  pre- 
ceded by  the  appearance  of  a  diffusely  red  erythematous  or  dark 
swelling  of  the  general  surface.     The  skin  is  thickened,  soft,  mac- 


CONGENITAL  ICHTHYOSIS.  893 

erated,  and  velvety  to  the  toucli.  The  epidermis  can  be  moved  on 
the  corium  beneath.  The  pressure  of  the  clothing  or  bedclothes  may 
also  produce  this  effect.  Minute  vesicles  appear,  and  coalesce  to 
form  larger  vesicles  or  bullae.  Vesicles  or  bullse  of  large  size  which 
may  be  either  partly  filled  with  serum  or  empty  are  formed.  They 
are  never  tense,  and  finally  open  or  tear,  leaving  the  red  moist 
corium  exposed.  The  surface  of  the  body  has  a  beefy-red  color,  and 
is  covered  here  and  there  with  patches  of  dry,  adherent  epidermis ;  in 
other  areas  the  corium  is  exposed.  There  are  rhagades  at  the  angles 
of  the  mouth  and  on  the  trunk.  The  upper  extremities  become 
affected  later  than  the  lower  ones.  Whole  areas  of  the  trunk  and 
body  are  denuded  of  epidermis.  After  the  vesicles  burst  and  leave 
the  corium  exposed,  the  epidermal  layer  of  the  skin  is  still  adherent 
in  places,  while  the  desquamated  skin  is  rolled  up  into  cord-like  masses 
and  hangs  loosely  exposed.  If  recovery  takes  jDlace,  the  corium  be- 
comes covered  with  a  delicate  epidermis,  which  gradually  assumes  the 
normal  pinkish-white  hue.  Some  cases  may  run  an  afebrile,  others 
a  febrile  course. 

Course  and  Prognosis.. — A  few  of  the  cases  recover.  Ritter  lost  50 
per  cent,  of  his  cases,  and  Escherich  90  per  cent.  The  infants  may 
die  from  the  sixth  to  the  tenth  day  or  after  the  third  week,  when 
much  of  the  skin  has  undergone  retrograde  changes.  The  cases  may 
show  umbilical  infection  or  bronchopneumonia,  pointing  to  the  septic 
nature  of  the  disease. 

Treatment. — The  infants  are  kept  warm  by  artificial  means,  such 
as  warming  bottles  or  an  incubator.  They  are  not  bathed.  The  skin 
is  protected  by  the  application  of  bland  salves  or  gauze  moistened 
with  a  mixture  of  linseed  oil  and  lime-water  (Escherich).  Some 
physicians  add  a  small  quantity  of  salicylic  acid  to  the  salves.  As 
soon  as  the  skin  has  become  dry,  Lassar's  paste  and  powdered  zinc 
are  applied. 

CONGENITAL  ICHTHYOSIS. 

(Cutis  Sebacea.) 

Ballantyne  gives  an  exhaustive  description  of  this  affection,  which 
is  really  a  perpetuation  of  a  foetal  condition  into  post-natal  life.  The 
foetal  skin  has  a  tendency  to  seborrhoea.  This  is  apparent  after  birth, 
and  is  evident  during  infancy  as  seborrhoea  of  the  scalp.  The  sebor- 
rhoea may  affect  different  parts  of  the  body  and  may  form  thin  shining 
scales  on  the  surface  of  the  skin.  There  may  be  secondary  eczema. 
The  mild  forms  may,  with  ordinary  cleanliness  and  the  application  of 
bland  salves,  disappear  a  few  weeks  after  birth.  The  form  described 
by  Hebra  and  Kaposi  as  ichthyosis  congenita  is  an  extreme  example 


894  DISEASES  OF  TEE  SKIN. 

of  the  tendency  of  the  foetal  skin  to  the  formation  of  sebum  or  vernix. 
The  increased  secretion  continues  after  birth.  The  infant  appears 
to  be  covered  with  a  horny  mass  which  almost  envelops  it. 

This  parchment-like  covering  is  absent  at  the  mouth,  eyes,  anus, 
and  on  the  scalp.  The  surface  is  firm  and  of  a  yellow  or  brownish- 
red  tint  (Escherich).  The  hardness  and  brittleness  of  the  skin 
render  motion  painful.  The  infant  is  enclosed  as  if  in  case-armor. 
The  face  has  a  mask-like  expression.  The  skin  is  broken  in  places, 
especially  at  the  joints.  At  these  fissures  the  true  skin  is  seen.  At 
the  broken  spots,  the  sebum  is  seen  to  be  composed  of  lamellae,  from 
the  posterior  aspect  of  whichprojectwarty  excrescences  corresponding 
to  the  lanugo  and  openings  of  the  sebaceous  glands.  These  may  be 
removed  from  the  skin.  If  the  infant  lives,  the  layers  of  sebum  are 
thrown  off  gTadually,  and  the  skin  is  left  with  a  general  seborrhoea 
of  the  ordinary  type.  Escherich  predicts  a  favorable  course  in  most 
of  these  cases,  but  some  die  shortly  after  birth.  Pathologically  there 
is  a  great  thickening  of  the  rete  Malpighii ;  the  corium  shows  no 
changes;  the  sebaceous  glands  are  atrophied  or  the  seat  of  fatty  degen- 
eration; the  sudoriparous  glands  are  normal.  After  the  layers  of 
horny  sebum  have  peeled  off,  the  skin  underneath  appears  pink  or 
red  or  shining,  and  is  covered  with  seborrhoeal  scales. 

Treatment. — The  treatment  consists  in  the  application  of  emol- 
lients and  in  washing  the  skin  daily  or  bathing  the  infant  in  perman- 
ganate of  potassium  (grains  xv  (1.0)  to  the  bath  water).  Salicylic 
and  boric  ointments  are  applied  after  the  baths. 

PEMPHIGUS  NEONATORUM. 

Pemphigus  neonatorum  is  a  contagious,  infectious  disease  of  the 
skin  occurring  in  the  newborn  infant.  It  has  also  been  observed 
later  in  infancy.  It  usually  appears  at  the  end  of  the  first  or  second 
week,  and  affects  the  whole  surface,  except  the  palms  of  the  hands 
and  the  soles  of  the  feet.  There  appear  on  the  surface  of  the  trunk 
and  extremities  small  and  large  vesicles  containing  cloudy  serum. 
These  burst  and  leave  a  round  patch  of  skin,  which  dries  and  is 
covered  with  yellowish  scales.  The  vesicles  may  attain  the  size  of 
bullae.  They  may  be  discrete  or  involve  the  whole  bod}^,  so  that  the 
surface  is  after  a  time  denuded  of  the  epithelial  layer.  The  disease 
may  in  the  beginning  be  confounded  with  dermatitis  exfoliativa. 
The  vesicles  may  appear  in  crops ;  the  recurrences  may  extend  over  a 
period  of  from  two  to  four  weeks. 

There  are  two  forms,  in  one  of  which  the  disease  is  mild ;  in  the 
other  it  runs  a  malignant  course,  and  from  the  outset  large  areas  of 
skin  are  denuded  of  epithelium  by  the  bursting  of  enormous  bulhe. 


PEMPHIGUS  NEONATORUM.  895 

The  infants  pass  into  an  asthenic  condition,  refuse  nourishment,  and 
die  in  a  few  days. 

Etiology. — Both  forms  appear  in  epidemics.  The  disease  occurs 
sporadically.  The  essential  cause  is  still  obscure.  Strelitz,  Demme, 
Almquist,  and  Escherich  have  isolated  a  white  staphylococcus  from 
the  serum  of  the  vesicles.  Its  role  as  an  etiological  factor  is  not  as 
yet  understood.  Escherich  is  inclined  to  class  this  form  of  pemphigus 
with  other  infectious  skin  diseases,  such  as  the  impetigo  of  Wilson 
or  Bockhart,  and  folliculitis  abscedens,  in  which  certain  conditions 
favor  serous  infiltration  of  the  horny  layer  of  the  skin  and  extensive 
desquamation  from  the  corium.  He  believes  the  exciting  cause  to 
be  the  pus  cocci  found  in  other  forms  of  impetigo.  Escherich  has 
suggested  the  use  of  the  name  "  Impetigo  Bullosa  ISTeonatorum  or 
Infantum  "  for  this  affection. 

Prognosis. — The  prognosis  is  favorable  if  the  process  confines  itself 
to  the  superficial  layers  of  the  skin.  If  the  deeper  layers  are  attacked, 
abscesses  and  general  sepsis  result. 

Treatment. — Escherich  recommends  that  the  affected  parts  be 
washed  with  soap  and  water,  and  dressed  with  a  2  per  cent,  ointment 
of  white  precipitate.  Baths  are  not  given.  Those  who  are  inter- 
ested in  the  epidemiological  aspect  of  this  disease  will  find  the  mono- 
graph of  Richter  exhaustive. 


INDEX. 


Abdomen,  boat-shaped,  in  meningitis,  44 
contour  of,  in  tumor,  44 
distension  of,  in  ascites,  44 
examination  of,  44 
free  fluid  in,  44 
inspection  of,  44 
in  intussusception,  44,  45 
pain  in,  45 
palpation  of,  44 
polypoid  tumors  in,  45 
retracted  in  septic  peritonitis,  44 
tenseness  of,  in  colic,  44 
tumor  of,  dyspnoea  in,  615 
tympanites  of,  liver  dulness  in,  44 

in  peritonitis,  44 
Abdominal  pain,  45 

in  appendicitis,  45 

in  pericarditis,  45 

in  pleurisy,  45 

in  pneumonia,  45 

typhoid   fever,    318.      See    Ty- 
phoid Fever 
Abscess  of  brain  in  scarlet  fever,  275 
of  breast,  128,  129 
cerebral,  sudden  death  in,  21 
metastatic,  in  arteritis  umbilicalis, 
210 

in  phlebitis  umbilicalis,  211 
perinephritic,    diagnosis    of,    from 

acute  appendicitis,  550 
peri-oesophageal,  491 

diagnosis  of,  491 

etiology  ot,  491 

prognosis  of,  492 

symptoms  of,  491 

treatment   of,  492 
periproctitic,  in  dysentery,  532 
rectal  exploration  in,  46 
retro-oesophageal,  491 
retropharyngeal,  585 

diagnosis  of,  587 

diphtheria  and,  389 

etiology  of,  586 

in  follicular  amygdalitis,  590 

forms  of,  585 

frequency  of,  586 

idiopathic,  585 

lymph-nodes  and,  585 

onset  of,  586 

prognosis  of,  587 

in  scarlet  fever,  271,  276 

sudden  death  in,  20 

symptoms  of,  586 

treatment  of,  587 

voice  in,  587 

57  897 


Abscess    of    scalp,    diagnosis    of,    from 
cephaloheematoma,  235 
of  skin  in  scarlet  fever,  272 
subcutaneous,  in  typhoid  fever,  327 
subphrenic,  672 

diagnosis  of,  673 

gas  in,  673 

metallic  tinkle  in,  673 

physical  signs  of,  673 

simulating      enlargement       of 

liver,  562 
succussion  in,  673 
treatment  of,  673 
visceral  displacem.ent  in,  670 
of  thymus  gland,  729 
Acetone  breath  in  cyclic  vomiting,  505 
in  diabetes  mellitus,  712 
in  urine,  33 
Acetonuria,  33 
Achondroplasia,  250 
Acids,  fatty,  in  human  milk,  93 
Acorn  cocoa,  118 

composition  of,  119 
i^ddison's  disease,  753 

etiology  of,  753 
pigmentation  in,  754 
symptoms  of,  753,  754 
treatment  oi,  754 
Adenitis,  acute,  716 

diagnosis  of,  716 

from   infectious   parotitis, 
717 
etiology  of,  716 
frequency  of,  716 
pyogenic  infection  and,  716 
symptoms  of,   716 
treatment  of,  717 
facial  expression  in,  39 
retropharyngeal,     enlargement     of 
lymph-nodes  in,  715 
in  scarlet  fever,  276 
tuberculous,     diagnosis     of,     from 
Hodgkin's  disease,  747 
Adenoid  growths,  579 
age  and,  580 
bronchitis  and,  582 
deafness  and,  581 
diagnosis  of,  583 

from  nasal  polypi,  583 
emphysema  of  lung  and,  602 
enlargement     of     lymph-nodes 

in,  715 
etiology  of,  580 
-    examination  in,  method  of,  584 
facial  expression  in,  39 
lymphatism  and,  580,  581 


898 


IXDEX. 


Adenoid  groTrths,  mouth-breathing  and, 
581 
occurrence  of.  579 
paver  nocturnus  and.  822 
prognosis  of,  584 
rhinitis  and,  580 
situation  of,  580 
snoring  and,  581 
speech  and,  581 
•  symptoms  of,  580 
treatment  of,  584 

operative,  584,  585 

contra-indications  for, 

585 
indications  for,  5S4 
varieties  of,  582 
tumors  of  umbilicus,  207 
vegetations,  579 
Adenomata  of  rectum,  554 
Adenopathy,  syphilitic,  715 
Adherent  pericardium,  681 
Agenesis  corticalis,  849 
Agglutinins  in  human  milk,  97,  9 S 
Air.  open,  60 

Albinism,  nystagmus  in,  40 
Albumin  in  cerebrospinal  fluid,  77 
in  cow's  milk,  102 
role  of,  in  nutrition,  83,  84 
in  urine,  33 
Albuminoids,  digestion  of.  in  newborn. 

169 
Albuminuria  in  acute  gastro-enteric  in- 
fection, 520 
cyclic,  770 

diagnosis    of,    from    nephritis. 

772 
etiology  of,  771 
prognosis  of,'  772 
symptoms  of,  771 
treatment  of,  772 
urine  in,  771 
in  follicular  amygdalitis,  590 
in  influenza,  344 
lordotic,  770 
in  mumps,  371 
orthostatic,  770 
postural,  770 
in  scarlet  fever,  278 
Alcohol  in  human  milk,  97 
Alexins  in  human  milk,  17.  88,  89,  94.  95 
Allenbury's  food,  120  '      ' 
Allergistie  reaction  in   tuberculin   test, 

426 
Amaurosis  in  measles,  304 

in  scarlet  fever,  279 
Amaurotic  idiocy,  837 
Amblyopia,  infantile,  nystagmus  in.  40 

in  typhoid  fever,  328 
Ama'bie  colitis,  534 
dysentery,  534 
Amorphism,  dental,  in  syphilis,  473 
Amygdalitis,  follicular,  589 
age  and,  589 
albuminuria   in,  590 
diagnosis  of,  590 
duration  of,  590 


Amvgdalitis,  follicular,  endocarditis  in, 
590 
etiology  of,  589 
nephritis  in,  590 
otitis  in,  590 
prognosis  of,  590 
retropharvngeal      abscess      in, 

590 
rheumatic  cases  of,  590 
symptoms  of,  589 
tonsils  in,  589 
treatment  of,  590 
lacunar,  589 
Amylase  in  human  milk,  94 
Amylolytic  ferments  in  newborn,  169 
Anaemia,  736 

acquired,  736 

congenital,  736 

in  cystitis,  795 

enlargement  of  lymph-nodes  in,  716 

essential,  736 

in  habitual  constipation,  539 

infantum  pseudoleukaemiea,  739 

enlargement    of    liver    in, 
562 
lymphatica,  747 
pernicious,  752 

blood  in,  752 
primary,  736 

progressive,  in  uncinariasis,  559 
pseudoleuksemic,  739 
blood  in,  741 
bone-marrow  in,  740 
diagnosis  of,  742 
etiology  of,  740 
kidney  in,  740 
liver  in,   enlargement   of,   740, 

741 
lymph-nodes  in,   741 
pathology  of,  740 
rachitis  and,  741 
skin  in,  740 

si:>leen  in,  enlargement  of,  740 
symptoms  of,  740 
treatment  of,  742 
in  rachitis,  245 
scarlet  fever  and,  280 
secondary,  737 
simple,  737 

blood  in,  737,  738 
etiology  of,  737 
hemoglobin  in,  738 
hydrasmia  in,  737 
symptoms  of,  737 
Anaemic  cardiac  murmurs,  705 
Anaesthesia,  sudden  death  in,  22 
Anchylostoma  duodenale,  558 
Aneurysm,  sudden  death  in,  20 
Angina,  591 

catarrhal,  589 

in     chronic     valvular     disease     of 

heart,  703 
membranous,  in  scarlet  fever,  270 
in  scarlet  fever,  267,  270 
Anorchidism,  181 
Anorexia  in  hysteria,  804 


INDEX. 


899 


Anterior  jioliomyelitis,  861 
Antitoxin,  diphtheritic,  397 

eruptions,  diagnosis  of,  from  mea- 
sles, 307 
in  human  milk,  97,  98 
Antipyretics,  administration  of,  63,  64 
Anus,  fissure  of,  553 

constipation  in,  553 
diagnosis  of,  553 
symptoms  of,  553 
in  syphilis,  553 
treatment  of,  553 
prolapse  of,  552 
spasm  of,  554 

treatment  of,  554 
Aortic  cardiac  murmurs,  705 
Aphasia  in  acute  encephalitis,  860 
in  scarlet  fever,  279 
in  typhoid  fever,  328 
Aphthge,  Bednar's,  62,  476 

diagnosis  of,  from  diphtheria,  395 
Aphthous  stomatitis,  478 
Apncea  in  laryngismus  stridulus,  817 
Apoplexy,    sudden    death    in    newborn 

and,  180 
Appendicitis,  abdominal  pain  in,  45 
acute,  547 
catarrhal,  548 

symptoms  of,  548 
diagnosis  of,  549 

from  intussusception,   545 
from  lobar  pneumonia,  551 
from      perinephritic      ab- 
scess, 550 
from    tuberculous    perito- 
nitis, 550 
from  typhoid  fever,  5'51 
fever  in,  550 
frequency  of,  547 
gangrenous,  549 

symptoms  of,  549 
McBurney's  point  in,  550 
pain  in,  550 
palpation  in,  549 
percussion  in,  550 
perforative,  548 

symptoms  of,  548 
prognosis  of,  551 
rectal  examination  in,  550 
suppurative,  548 
symptoms  of,  548 
tympanitis  in,  550 
varieties  of,  547 
chronic,  551 

symptom.s  of,  551 
treatment  of,  552 
colic  in,  509 
empyema  and,  652 
diagnosis  of,  from  gonococcal  peri- 
tonitis, 571 
from  pneumococcal  peritonitis, 

572 
from  typhoid  fever,  330,  332 
vomiting  in,  507 
Appendix  vermiformis,  547 
anatomy  of,  547 


Appendix    vermiformis,     palpation     of, 
547 
position  of,  547 
size  of,  547 
Areas,  painful,  in  spine,  47 
Armour's  beef -extract,  118 
beef-juice,  115 
vrine  of  peptone,  115 
Arnold's  sterilizer,  107 
Arrhythmia,  30 

in   myocarditis,   708 
in  newborn,   168 
Arrowroot,  composition  of,  115 
gruel,  115 

preparation  of,  115 
Arterial  murmurs,  accidental,  706 
Arteriosclerosis,    hypertrophy    of    heart 

in,  709 
Arteritis  umbilicalis,  209 

abscesses,  metastatic  in,  210 
course  of,  210 
etiology  of,  209 
Hennig's  symptom  in,  210 
pathology  of,  209 
prognosis  of,  210 
symptoms  of,  210 
Arthritic  pains  in  chorea,  825 
Arthritis,  bronchopneumonia  and,  642 
deformans,  463 
in  dysentery,  532 
rheumatoid,  463 

lymph-nodes  in,  464 
onset  of,  463 
prognosis  of,  464 
symptoms  of,  463 
treatment  of,  464 
scarlet  fever  and,  277 
in  typhoid  fever,  328 
vulvovaginitis  and,  792 
Arthrogryposis,  808.     See  Tetany 
Articular  rheumatism,  acute,  459 
Artificial  infant-feeding,  133 

respiration,  195 
Ascarides  lumbricoides,  556 
Ascaris    lumbricoides,    peritonitis    and, 

569 
Ascites,  45,  567 
chylous,  568 

etiology  of,  568 
diagnosis  of,  568 

from  cysts   of  peritoneal   cav- 
ity, 568 
from     tumors     of     peritoneal 
cavity,  568 
distension  of  abdomen  in,  44 
dyspnoea  in,  615 
etiology  of,  568 
forms  of,  568 
treatment  of,  568 
Asphyxia  in  congenitally  weak  infants, 
198 
in  newborn,  193 

after-treatment  in,  197 
artificial  respiration  in,  195, 196 
bath  in,  195 
definition  of,  193 


900 


INDEX. 


Asjjhyxia     in     newborn,     diagnosis     of, 
195 
from  acute  fatty  degener- 
ation of  newborn,  221 
from       cerebral       hemor- 
rhage, 195 
etiology  of,  193 
extra-uterine,  193,  197 
intra -uterine,  193 
pathology  of,  194 
prognosis  of,  195 
symptoms  of,  194 
treatment  of,  195 
Asthma  crystals  in  fibrinous  bronchitis, 
60l" 
dyspnoea  in,  614 
in  emphysema  of  luugs,  604 
thymic,  729,  816 
Ataxia,  Friedreich 's,  ataxic  gait  in,  50 
patellar  reflex  in,  49 
hereditary,  858 

diagnosis  of,  859 

from  tabes,  859 
muscular  power  in,   858 
nystagmus  iu,  858 
prognosis  of,  859 
sensory  disturbances  in,  858 
symptoms  of,  858 
treatment  of,  859 
in  typhoid  fever,  328 
Ataxic  gait,  50 
Atelectasis,  198 
acquired,  198 
auscultation  in,  199 
in  bronchopneumonia,  634 
compression,  198 

in  congenitally  weak  infants,  184 
convulsions  in,  200 
diagnosis  of,  200 
dyspnoea  in,  199 
etiology  of,  198 
in  measles,  302 
obstructive,  198 
palpation  in,  199 
percussion  in,  199 
prognosis  of,  200 
rales  in,  200 
sudden  death  from,  19 
symptoms  of,  199 
treatment  of,  200 
Athetoid  movements,  diagnosis  of,  from 

chorea,  828 
Athetosis    in    infantile    cerebral    palsy, 

848 
Athrepsia,  260 
Athyreosis,  718,  722 
Atresia,  congenital,  of  oesophagus,  490 
Atrophic  paralysis,  acute,  861 
Atroj)hy   of   muscle   in   acute   poliomye- 
litis, 870 
infantile,  260 

carVjohydrates  in,  261 
cereals  in,  261 
etiology  of,  260 
fats  in,  261 
pathology  of,  261 


Atrophy,  infantile,  symptoms  of,  262 
treatment  of,  263 
of  liver,  acute  yellow,  567 
muscular,  49 

in  diphtheria,  49 
facio-seapulo-humeral,      Dejer- 
ine  type  of,  873 
Landouzy  type  of,  873 
in  infectious  diseases,  49 
in  joiut-afl:ections,  49 
in  neuritis,  49 
in  poliomyelitis,  49,  870 
progressive    muscular,   Erb's   tvpe, 
872 
juvenile  form  of,  872 
Auricular    septum,    congenital    defects 
of,  689 
ventricular   septum,   congenital   de- 
fects of,  689 
Aura  in  epilepsy,  820 
Auto-infection  in  sepsis  in  newborn,  202 


Babixski's  reflex,  49 

in     cerebrospinal     meningitis, 

352 
in  tuberculous  meningitis,  435, 
439 
Bacillary  infection  of  human  milk,  97 
Bacilluria,  796 

Bacillus  eoli  communis  in  cystitis,  793 
diphtherife,  379 

of  Klebs-Loffler  iu  diphtheritic  rhi- 
nitis, 578 
mesentericus     vulgatus     in     cows' 

milk.  105 
potato,  in  cows'  milk,  105 
subtilis  iu  cows'  milk,  105 
Bacteria  iu  cerebrospinal  fluid,  76 
in  human  milk,  94 
of  mouth,  62 
newborn  and,  17,  IS 
Bacterium  coli  communis  in  acute  peri- 
tonitis, 569 
lactis  aerogenes  in  cows '  milk,  105 
Bad  habits,  805 
Balanitis,   enlargement   of  lymph-nodes 

in,  715 
Barley,  dextrinized,  114,  158 

Eobinson's  patent,  114,  158 
water,  114 

in      gastro-enteritic      disturb- 
ances, 114 
preparation  of,  114 
Barley-gruel,  157 

preparation  of,  158 
use  of,  157 

in  newborn,  157,  158 
Barlow's  disease    254.     See  Scorbutus, 

infantile 
Bartholini's      glands,      metastasis      of 

mumps  to,  371 
Basedow's  disease,  facial  expression  in, 

38 
Basilar  ir.cningitis,  432 


INDEX. 


901 


Bath,  Brand,  65 

in  congenitally  Aveak  infants,  190 
daily,  54 

temperature  of  Avater  for,  54 
time  for,  54 
first,  53 

drying  after,  54 
rapidity  of,  54 
temperature  of  room  for,  53 

of  water  for,  53 
water  for    ;jo,  54 
full,  65 

in  pneumonia,  65 
in  scarlet  fever,  65 
in  typhoid  fever,  65 
hardening  with,  55 
in  premature  infants,  55 
reaction  in,  55 
sponge,  64,  65 
Bed,  58,  59 

mattress  of,   59 
pillow  of,  59 
Bednar  's  aphthae,  62,  476 
etiology  of,  476 
in  sepsis  in  newborn,  203 
treatment  of,  476 
Beef-broth,  118 

composition  of,  118 
Beef -extracts,  117 

composition  of,  118 
varieties  of,  118 
Beef -juice,  composition  of,  115 

varieties  of,  115 
Beer,  effect  of,  on  human  milk,  96 
Bell's  paralysis,  851 
Benger's  food,  120 
Biedert's  mixture,  133,  134 
Bilateral  empyema,  671 
Bile  in  newborn,  169 
Bile-ducts,    congenital    obstruction    of, 
564 
enlargement    of    liver    in, 
565 
of  spleen  in,  565 
etiology  of,  564 
jaundice  in,  564 
pathology  of,  565 
symptoms  of,  564 
Biliary  pigment  in  urine.  31 
Bilirubin  in  meconium,  174 
Binaural  stethoscope,  42 
Binder,  body-,  61 
Birth,  injuries  during,  232 

loss  of  weight  following,  24 
palsy,  232,  843 
paralysis,  232 
premature,  19 

sudden  death  in,  10 
Blennorrhcea   of  umbilicus,  207 

urogenital,  790 
Blindness,  40 

Blood,  carbohydrates  in,  85 
characteristics  of,  739 
circulation  of,  28 
diseases  of,  734 
haemoglobin  of,  736 


Blood  in  newborn,  168 

erythrocytes  in,  169,  734 
histology  of,  169 
leucocytes  in,  169,  735 
polycythemia  in,  734 
in  rachitis,  245,  246,  735 
specific  gravity  of,  736 
Blood-cells,  red,  734 

white,  735 
Boat-shaped  abdomen,  44 
Bodies  of  Lourie,  89,  90 
Body,  length  of,  26 
in  boys,  26 
in  girls,  26 
increase,  26 
Body-binder,  61 

Body-temperature  in  newborn,  170 
Bone,   changes   of,   in    acute   infectious 
osteomyelitis,  757 
in  otitis,  760 
craniotabes  of,  756 
diseases  of,  755 

pains  in,  755 
disturbances   from   sterilized   milk, 

110,  111      • 
in  rachitis,  755 
of  skull,  syphilis  of,  756 
tuberculosis  of,  756 
syphilis  of,  756 

differentiation    from    tubercu- 
losis of  bones,  755,  756 
tuberculosis  of,  755 

differentiation     from     syphilis 
of  bones,  755,  756 
Bone-marrow  in  leukajmia,  744 

in  pseudoleukaemic  angemia,  740 
Botalli,  duct  of,  167 
Bothriocephalus  latus,  558 
Bottle,  nipples,  care  of,  62,  112 
nursing.  111 

care  of.  111 
Freeman's,  111 
warming  of,  112 
warmer,   Sobel's,   112 
Bottle-fed  children,  increase  of  weight 
in,  25 
temperature  in,  30 
urine  in,  31,  32 
Bovinine,  115 
Bovril,  118 

"Bow-leg"  deformity  in  rachitis,  244, 
Bradycardia  in  hysteria,  805 
in  lobar  pneumonia,  621 
in  myocarditis,  708 
Brain,   abscess   of,    diagnosis   of,    from 
convulsions  in  infancy,  800 
vomiting  in,  508 
basilar  disease  of,  facial  palsy  and, 

853 
cortex  of,  tumors  of,  841 

symptoms  of,  841 
cysts  of,  840 
.    dropsy  of,  833 

ganglia  of,  tumors  of,  842 
symptoms  of,  842 
gliomata  of,  840 


902 


INDEX. 


Brain,  sarcomata  of,   840 
tubercle  of,  840 
tuberculosis  of,  443 
tumor  of,  840 

cerebrospinal  fluid  in,  76 
convulsions  in,  841 
diagnosis     of,     from     convul- 
sions in  infancy,  800 
from  epilepsy,  821 
etiology  of,  840 
forms  of,  840 
frequency  of,  840 
headache  in,  840 
location  of,  840,  841,  842,  843 
nausea  in,  841 
optic  neuritis  in,  841 
patellar  reflex  in,  49 
pulse  in,  841 
respiration  in,  841 
symptoms  of,  840 
vomiting  in,  508,  841 
vertigo  in,  841 
Branchial  cysts  of  oesophagus,  488 

fistulse  of  oesophagus,  488 
Brand  bath,  65 

in  typhoid  fever,  333 
Brand's  beef -extract,  118 
beef -juice,  115 
beef-pepjtone,  116 
Breast,  abscess  of,  128,  129 

infectious  diarrhoea  from,  129 
caking  of,  129 

in  newborn,  231 
treatment  of,  129 
use  of  breast-pump  in,  129 
care  of,  127 
chicken-,  27 

colostrum  in,  appearance  of,  127 
lymphangitis  of,  129 
in  newborn,  171 
milk  in,  171 

biochemical  theory  of,  171 
composition  of,  171 
niftples  of,  care  of,  61 
nursing  of  infants  at,  129 
placing  of  infants  at,  128 
Breast-fed  children,  increase  of  weight 
in,  25 
temperature  in,  30 
urine  in,  31,  32 
Breast-feeding,  colic  in,  130,  131 
efficient,  signs  of,  130 
inefficient,  signs  of,  130 
stools  in,  variation  of,  130,  131 
Breast-milk.     Hee  Milk,  human 
Breathing,  bronchial,  614 
bronchovesicular,  614 
normal,  613 
puerile,  613 
Brack's  nursing  tube,  189,  190 
Bright 's    disease,    contra-indication    to 

maternal  nursing,  124 
Bronchi,  diseases  of,  597 
Bronchial  breathing,  614 

nodes  in  congenitally  weak  infants, 
184 


Bronchiectasis,  606 

Ijronchophony  in.  609 
chest  in,  deformity  of,  609 
complications  of,  609 
congenital.  606 
cough  in,  608 
course  of,  609 
cysts  in,  607 
diagnosis  of,  609 
dyspnoea  in,  608 
empyema  and,  609 
etiology  of.  607 
expectoration  in,  608 
fever  in,  608 
foreign  bodies  and,  607 
gangrene  of  lung  and,  609,  610 
haemoptysis  in,  609 
inflammatory,  607 
pathology  of,  607 
physical  signs  of,  609 
pleurisy  and,  607,  609 
pneumonia  and,  607,  609 
symptoms  of,  608 
syphilis  and,  607 
treatment  of,  610 
tuberculosis  and,  609 
varieties  of,  606 
Bronchitis,  acute  simple,  597 
age  and,  597 
auscultation  in,  599 
cough  in,  598 
etiology  of,  597 
exanthemata  and,  597 
infectious     diseases     and, 

597 
palpation  in,  599 
pathology  of,  598 
percussion  in,  599 
physical  signs  of.  599 
rhachitis  and,  597 
sputum  in,  599 
symptoms  of,  598 
syphilis  and,  597 
treatment  of,  600 
adenoid  growths  and,  582 
bronchopneumonia  and.  635 
capillary,  treatment  of,  600 
chronic,  601 

in  emphysema  of  lungs,  601 
in  congenitally  weak  infants,  189 
flbrinous.  600 

asthma  crystals  in.  601 
casts  in,  601 
complications  of,  601 
cough  in,  601 
cyanosis  in,  601 
diagnosis  of,  601 
diphtheria  and,  600 
dyspnoea  in,  601 
etiology  of,  600 
fever  in,  601 

infectious  diseases  and,  600 
pathology  of,  601 
physical  signs  of,  601 
pneumonia  and,  600 
rales  in,  601 


INDEX. 


903 


Bronchitis,   fibrinous,   splenic  tumor  in, 
601 

symptoms  of,  601 

treatment  of,  601 

tuberculosis  and,  601 
in  influenza,  342 
in  measles,  302,  308,  309 
pertussis  convulsiva  and,  375 
plastic,  600 

putrid,  606.    See  also  Bronchiectasis 
in  sepsis  in  newborn,  201 
in  typhoid  fever,  328 
tuberculous,  601 
Bronchophony  in  bronchiectasis,  609 
bronchopneumonia  and,  643 
in  empyema,  662 
in  pleurisy,  662 
Bronchopneumonia,  632 
age  and,  632 
arthritis  and,  642 
atelectasis  in,  634 
bacteriology  of,  633 
bronchitis  and,  635 
bronchophony  in,  643 
cerebral  symptoms  in,  638 
chronic,  648 
complications  of,  640 
in  congenitally  weak  infants,   ]84, 

185 
convulsions  in,  634 
cough  in,  634 
cyanosis  in,  634,  635 
diagnosis  of,  645 

from  central  pneumonia,  644 

from  lobar  pneumonia,  645 
diarrhoeal  conditions  and,  640 
diphtheria  and,  388,  640 
dyspnoea  in,  634 
empyema  and,  652 
equivocal  signs  of,  644 
etiology  of,  633 
fever  in,  635 

gangrene  of  lungs  and,  640 
gastro-enteric  tract  in,  637 
hydrotherapy  in,  646 
in  influenza,  341 
measles  and,  302,  308,  639 
meningitis  and,  642 
occurrence  of,  632 
onset  of,  634 
osteomyelitis  and,  642 
otitis  and,  640,  759,  761 
pathology  of,  633 
pericarditis  and,  642 
pertussis  convulsiva  and,  375,  638 
persistent,  648 

blood  in,  649 

diagnosis  of,  650 

physical  signs  of,  650 

symptoms  of,  649 

treatment  of,  650 
physical  signs  of,  642 
pneumococcus  in,  633 
prognosis  of,  645 
pulmonary  tuberculosis  and,  422 
pulse  in,  636 
rales  in,  643,  644 


Bronchopneumonia,    scarlet    fever    and, 
639 

season  and,  632 

sex  and,  632 

sputum  in,  637 

stages  of,  642,  643 

surroundings  and,  632 

symptoms  of.  634 

treatment  of,  646 

tuberculous,  421 

tympanites  in,  637 

types  of,  634 

typhoid  fever  and,  326,  639 

varicella  and,  639 

vomiting  in,  637 
Bronchovesicular  breathing,  614 
Buhl 's  disease,  221.     See  also  Newborn, 

acute  fatty  degeneration  of 
Bui'goyne  's  beef -juice,  415 
Butter  milk,  117 

C 

Caking  of  breasts,  129 

in  newborn,  231 
Calculi,  biliary,  567 

renal,  775 
Calmette's  tuberculin  test,  424,  425 
Calories,  31 

in  carbohydrates,  87 

in  cows'  milk,  86 

in  fats,  87 

heat,  31 

in  human  milk,  86 

in  proteids,  87 

required  in  artificially  fed  infants, 
88 
Cancrum  oris,  483.     See  also  Noma 
Cantani's  salt-solution,  66 
Caput  succedaneum,  26 

diagnosis  of,  from  cephalohse- 
matoma,  235 
Carbohydrates,  in  blood,  85 

calories  in,  87 

in  cows'  milk,  85 

in  human  milk,  85 

in  liver,  85 

in  lymph,  85 

in  muscles,  85 

in  nutrition,  85 
Carbon  dioxide,  excretion  of,  in  respi- 
ration, 28 
Carbonic  acid  gas,  excretion  of,  by  in- 
fants, 88 
Carcinoma  of  kidney,  785 

of  thymus  gland,  729 
Cardiac  area,  42 

disease,  sudden  death  in,  20 

dyspnoea,  614 

hypertrophy  in  scarlet  fever,  280 

insufiiciency    in     chronic     valvular 
disease  of  heart,  700 

murmurs,  704 
Caries  of  bone,  facial  palsy  and,  852 
Carnrick's  peptonoids,  116 

soluble  food,  120 
Casein,  assimilation  of,  in  cows'   milk, 
103 


904 


INDEX. 


Casein,  assimilation  of,  in  human  milk, 
103 
in  cows'  milk,  91,  102,  103 
in  human  milk,  84,  91,  92,  103 
Caseinogen  in  human  milk,  91 
Casts  in  diabetes  mellitus,  712 

in  urine,  34 
Catalepsy,  814 

in  hysteria,  803 
symptoms  of,  814 
Cataract,  congenital,  nystagmas  in,  4C 

corneal,  nystagmus  in,  40 
Catarrh,  acute  nasal,  574 

bacterial     infection     and, 

574 
diagnosis  of,  575 
etiology  of,  574 
infectious     diseases     and, 

574 
prognosis  of,  575 
symptoms  of,  575 
treatment  of,  576 
chronic  nasal,  576 

etiolosfy  of,  576 
lymphatism  and,  576 
symptoms  of,  577 
treatment  of,  577 
enteric,  527 
Catarrhal  appendicitis,  acute,  548 
angina,  589 
croup,  593 
diphtheria,  384 

fever,  acute,  339.    See  also  Influenza 
icterus,  563 
influenza,  341 
laryngitis,  593 
otitis  media,  759,  760 
pneumonia,   632 
tonsillitis,  589 
Caustic  CESophagitis,  490 
Cephalohffimatoma,  26,  234 
complications  of,  235 
diagnosis  of,  235 

from  abscess  of  scalp,  235 
from  caput  succedaneum,  235 
from  hernia  of  brain,  235 
from  phlegmon  of  scalp,  235 
externa,  234 
interna,  234 
in  newborn,  235 
pathogenesis  of,  235 
prognosis  of,  235 
symptoms  of,  234 
treatment  of,  236 
Cerebellum,  tumors  of,  843 
symptoms  of,  843 
Cerebral  abscess,  otitis  and,  760 
diplegia,  843 

disease,  ataxic  gait  in,  50 
titubation,  50 
Cerebrospinal    fever,   347.     Sec   Menin- 
gitis, cerebrospinal 
fluid,  abnormal,  75 

specific  gravity  of,  75 
albumin  in,  77 
bacteria  in,  76 


Cerebrospinal  fluid,  blood  in,  75 
in  brain  tumor,  76 
cytology  of,  76 
in  hydrocephalus,  chronic,  76 
lymphocytosis  in,  76 
in     meningitis,     cerebrospinal, 
epidemic,  76 
sporadic,  76 
serosa,   368 
suppurative,  76 
tuberculous,  75 
normal,  74 
pressure  of,  76,  77 
meningitis,  347 
Cerebrum  in  newborn,  175 
Cereo,    in    preparation    of    dextrinized 

gruel,  158,  159 
Cervical  muscles,  spasm  of,  position  of 
head  in,  40 
weakness  of,  position  of  head 
in,  40 
Chapin  's    method    of    artificial    infant- 
feeding,  158 
Chapman 's  whole  flour,  121 
Charcot-Leyden      crystals     in      amcebic 

dysentery,  534 
Chemise,  60 

Chemism  of  respiration,  28 
Chest,  auscultation  of,  613 
cardiac  area  of,  42 
circumference  of .  27 
compress,  cold,  65 
examination  of,  40 

in  infants,  40,  41 
in  older  children,  41 
position  of  patient  in,  40 
fremitus  in,  611 
inspection  of,  42 
movements  of,  normal,  611 

restriction  of,  in  effusion,  611 
in  emphysema,  611 
in  scoliosis,  611 
palpation  of,  43 
percussion  of,  43 
shape  of,  27 

in  rachitis,  27 
Chest-wall,  resiliency  of,  611 
Cheyne-Stokes  respiration  in  septic  en- 
docarditis, 698 
in  tuberculous  meningitis,  434, 
439 
Chicken-breast,  27 

Chickenpox,  310.     See  also  Varicella 
Childhood,  constitutional  diseases  in,  18 
definition  of,  17 
infections  in,  18 
intestinal  disturbances  in,  18 
morbidity  in,  17 
respiratory  disturbances  in,  18 
Chill  in  onset  of  illness,  37 
<_'hlorosis.  738 

l)]ood  in,  738 
etiology  of,  738 
Cholecystitis  in  typhoid  fever,  333 
Cholera    asiatica    from    infected    cows' 
milk,  105 


INDEX. 


905 


Cholera  infantum,   521.     See  also   Gas- 
troenteric infection,  acute 

diagnosis  of,  523 

from    infectious    diseases, 
523 

hypodermoclysis  in,  66 

prognosis  of,  522 

symptoms  of,  521 

treatment  of,  523 
Chondrin,  84 

Chondrodystrophia  foetalis,  250 
diagnosis  of,  251 

from    osteogenesis    imper- 
fecta, 252 

long  bones  in,  250 

pathology  of,  250 

prognosis  of,  252 

skull  in,  250 

symptoms  of,  251 
hyperplastica,  250 
hypoplastica,  250 
Chondrogen,  82 
Chondromalacia  foetalis,  250 
Chorea,  822 

in  acute  articular  rheumatism,  462 
age  and,  823 
arthritic  pains  in,  825 
cardiac  murmurs  in,  827 

symptoms  in,   826 
diagnosis  of,  828 

from  athetoid  movements,  828 

from  chorea  insaniens,  831 

from  habit  movements,  828 

from  tic  convulsif,  828 
electric  reactions  in,  825 
electrica,  822 

endocarditis  and,  690,  693,  826 
epidemic,  823 
epilepsy  and,  825 
etiology  of,  823 
frequency  of,  823 
fright  and,  823 
habit  movements  in,  828 
Huntington's,  823 
infectious  diseases  and,  824 
insaniens,  822,  829 

delirium  in,  830 

diagnosis      of,      from      simple 
chorea,  831 

fever  in,  830 

symptoms  of,  830 

sex  and,  829 

treatment  of,  831 
laryngeal,  822 
lymphatism  and,  823 
major,  822 

mental  symptoms  in,  828 
minor,  822 

multiple  neuritis  and,  825 
muscular  twitchings  in,  825 
night-terrors  in,  825 
onset  of,  824 
pathology  of,  824 
pericarditis  in,  826 
post-hemiplegic,   in   infantile    cere- 
bral palsy,  848 


Chorea,  prognosis  of,  828 

refractive  errors  and,  823 

rheumatism  and,  823,  824 

scarlet  fever  and,  281 

sex  and,  823 

speech  in,  826 

Sydenham's,  822 

symptomatic,  822 

symptoms  of,  824 

temjierature  in,  827 

tongue  in,  825 

trauma  and,  823 

treatment  of,  829 

urine  in,  826 

wrist-drop  in,  825 
Chvostek's  symptom  in  status  lymphat- 
icus,  730 
in  tetany,  811 

in  tuberculous  meningitis,  435 
Chylous  ascites,  568 

Clubbed  fingers  in  stenosis  of  pulmon- 
ary artery,  688 
Clothing,  60 

of  congenitally  weak  infants,  190 
Circulation  in  newborn,  167 
Circulatory  disturbances,  sudden   death 
in,  20 

system,  diseases  of,  674 
Cirrhosis  of  liver,  565 
Cocoa,  acorn,  119 

Coffee,  effect  of,  on  human  milk,  97 
Cold  chest  compress,  65 

pack,  65 

sense  in  newborn,  177 
Colic,  508 

in    acute    gastro-enteric    infection, 
521,  526 

in  bottle-fed  infants,  152,  153 

in  breast-feeding,  130,  131 

cause  of,  508 

colostrum  corpuscles  and,  130,  131 

symptoms  of,  508 

tenseness  of  abdomen  in,  44 

treatment  of,  509 

tympanites  and,  508 
Colicystitis,  193.     See  also  Cystitis. 
Colitis,  amoebic,  534 

contagiosa,  528 
Colles's  law  in  hereditary  syphilis,  448 
Collogen,  82 

Colon,  congenital  dilatation  of,  540 
prognosis  of,  540 
symptoms  of,  541 
treatment  of,  542 
Colostrum,  89 

appearance  of,  in  breast,  127 

color  of,  89 

coloring-matter  of,  90 

composition  of,  89 

corpuscles,  89,  90 

colic  and,  130,  131 

crescents  of,  89,  90 
.    decomposition  of,  on  nipples,  128 

disappearance  of,  90 

Lourie's  bodies  in,  89,  90 

microscopic  appearance  of,  89,  90 


906 


INDEX. 


Colostrum,  physical  properties  of,  89 
specific  gravity  of,  89 
time  of  appearance  of,  89 
CondeDsed  milk,  113 
Congenital  anemia,  736 
bronchiectasis,  606 
constipation,  535 
dilatation  of  colon,  540 
hydrocele,  182 
ichthyosis,  893 
internal  hydrocephalus,  833 
pyloric  spasm,  511 
rachitis,  237 
stridor  of  infants,  815 
syphilis,  448 
tuberculosis,  419 
Congenitally  weak  infants,  183 
Conjunctival  tuberculin  test,  425 
Conjunctivitis  blennorrhceica,  228 
in  measles,  295,  304 
in  scarlet  fever,  276 
vulvovaginitis  and,  792 
Conrad 's  lactobutyrometer,  100 

lactodensimeter,  100 
Consanguinity,  pseudohypertrophic  mus- 
cular paralysis  and,  873 
Constipation,  535 
acquired,  536 
acute,  536 

diagnosis  of,  536 
foreign  bodies  and,  536 
intussusception  and,  536 
peritonitis  and,  536 
strangulation  and,  586 
chronic,  536 

anal  fissure  and,  537 
new  growths  and,  537 
in  acute  nephritis,  780 

peritonitis,   569 
in  artificial  infant-feeding,  152 
congenital,  535 

absence  of  anus  and,  535 
malformations  and,  535 
in  fissure  of  anus,  553 
from  frozen  milk.  111 
habitual,  chronic,  537 

anajmia  in,  539 
diet  in,  539 
enemata  in,  540 
etiology  of,  537 
habits  in,  540 
heredity  and,  538 
incorrect  feeding  and,  538 
massage  in,  540 
predisposition  toward,  537 
rachitis  and,  537 
stools  in,  538 
symptoms  of,  538 
treatment  of,  539 
in  pyloric  spasm,  513 
from  sterilized  milk,  108 
Constitutional  diseases,  711 

in  childhood,  18 
Contractures  in  infantile  cerebral  palsy, 

846 
Convulsions  in  infancy,  797 


Convulsions    in    infancy,    alcohol    and, 
798,  799 
coma  in,  800 
diagnosis  of,  800 

from  abscess  of  bi'ain,  800 
from  meningitis,  800 
from  tetany,  801 
from  tumor  of  brain,  800 
duration  of,  800 
etiology  of,  797 
gastro -enteric  disease  and,  798 
heredity  and,  798 
pathology  of,  799 
prognosis  of,  801 
symptoms  of,  799 
treatment  of,  801 
in  infantile  cerebral  palsy,  845 
in  scarlet  fever,  279 
in  tumor  of  brain,  841 
Convulsive  forms  of  hysteria,  803 
Coomb's  malted  food,  121 
Coprolalia  in  tic,  832 
Cord,  umbilical,  52.      See  Umbilical  cord 
Corneal  ulcerations  in  measles,  304 
Corpuscles,  colostrum,  89,  90 
Coryza  in  measles,  294,  295,  296 
Cows'  milk.     See  Milk,  cows' 
Cranial  bones  in  congenital  internal  hy- 
drocephalus, 834 
Cranio schisis,  880 

Craniotabes   in   congenital   internal  hy- 
drocephalus, 834 
laryngismus  stridulus  and,  817 
in  rachitis,  237,  240,  245 
shape  of  head  and,  38 
Crawling,  development  of,  35 
Crede  method,  56 

in  ophthalmia  neonatorum,  229 
Crepitations,  pleuritic,  in  emjDyema,  660 
Crepitus  of  joints,  46,  47 
Crescents  of  Lourie,  89,  90 
Crescent-shaped  bodies  in  human  milk, 

93 
Cretinic  form  of  idiocy,  878 
Cretinism,  718 
endemic,  718 

goitre  in,  718 
skull  in,  718 
sporadic,  719 

age  and,  719 
blood  in,  721 
bones  in,  724 
diagnosis  of,  724 

from  dwarfism  with  idiocy, 

725 
from  infantilism,  725 
from     Mongolian     idiocy, 

724 
from  rachitis,  246 
etiology  of,  722 
facial  expression  in,  720,  721 
genitals  in,  721 
hands  in,  722 
macroglossia  in,  722 
mental  dulness  in,  720,  722 
pathology  of,  723 


INDEX. 


907 


Cretinism,  sporadic,  skin  in,  720,  722 
symptoms  of,  719 
tongue  in,  722 
treatment  of,  725 

thyroid  extract  in,  725 
Croup,  catarrhal,  593 

spasmodic,  593 
Croupous  pneumonia,  615 
Crus  cerebri,  tumors  of,  842 
Cryptorchism,  182 
Curvature  of  spine,  47 
Cutaneous  scarification  tuberculin  test, 

425 
Cutis  sebacea,  893 
Cyanosis  in  bronchopneumonia,  634,  635 

in  congenital  heart  disease,  685 

in  fibrinous  bronchitis,  601 

in  onset  of  illness,  37 
■Cyclic  albuminuria,  770 

vomiting,  503 
Cystitis,  793 

anaemia  in,  795 

Bacillus  coli  communis  in,  793 

diagnosis  of,  795 

diphtheria  and,  793 

etiology  of,  793 

fever  in,  794 

frequency  of,  794 

influenza  and,  793 

intestinal  disturbance  and,  793 

measles  and,  793 

pain  in,  795 

pneumonia   and,   793 

scarlet  fever  and,  793 

symptoms  of,  794 

treatment  of,  796 

urine  in,  795 
Cysts  in  bronchiectasis,  606 

of  kidney,  784 

D 

Dactylitis  syphilitica,  455 

Dancing  mania  in  hysteria,  804 

Darby's  fluid  meat,  116 

Davidson's   shield  for  fissured  nijjples, 

128 
Deafness  in  newborn,  176 

in  scarlet  fever,  275 
Death,  sudden,  19 

in  aneesthesia,  22 

in  aneurysm,  20 

from  atelectasis,  19 

in  bronchopneumonia,  20 

in  cardiac  disease,  20 

in  cerebral  abscess,  21 

in  circulatory  disturbances,  20 

in   disease   of   central   nervous 

system,  21 
hyperthermia  and,  21 
intoxications  and,  21 
in  lumbar  puncture,  22 
lymphatism  and,  22 
in  newborn,  179 

apoplexy  and,  180 
hemorrhage  and,  180 


Death,   sudden,   in   newborn,   prodromes 
of,   180 
in  premature  birth,  19 
in  respiratory  disease,  20 
in  retropharyngeal  abscess,  20 
in  tetany,  22 
Dejerine  type  of  facio-scapulo-humeral 

muscular  atrophy,  873 
Den^yer's  peptone,  116 
Dentition,  abnormal,  471 
dental  erosions  in,  472 
incisions  of  gums  in,  474 
normal,  470 
pathology  of,  474 
in  rachitis,  471 
in  syphilis,  471 
Dermatitis  exfoliativa,  892 
course  of,  893 
etiology  of,  892 
prognosis  of,  893 
in  sepsis  in  newborn,  201 
symptoms  of,  892 
treatment  of,  893 
Desquamation  in  newborn,  17,  170 

in  scarlet  fever,  273 
Development,  mental,  34,  35,  36 

physical,  34,  35,  36 
Dew  method  of  artificial  respiration,  196 
Dextrinized  barley,  158 
gruel,  158 

in  artificial  infant-feeding,  158 
Dextrose  in  urine,  34 
Diabetes  insipidus,  712 

symptoms  of,  712 
urinary,  713 
treatment  of,  714 
mellitus,  711 

acetone  breath  in,  712 
casts  in,  712 
diagnosis  of,  712 
etiology  of,  711 
furuncles  in,  712 
polydipsia  in,  712 
pruritus  in,  712 
skin  in,  712 
symptoms  of,  711 
treatment  of,  712 
Diacetic  acid  in  urine,  33 
Diapers,  57 

change  of,  57 
material  for,  57 
washing  of,  57 
Diaphragmatic  respiration,  28 
Diarrhoea  in  acute  gastro-enteric  infec- 
tion, 520,  524 
in  congenitally  weak  infants,  185 
fat.  84,  153 
facial  expression  in,  39 
from  frozen  milk,  111 
in  influenza,  341 
in  measles,  303 
from  raw  milk,  110 
in  scarlet  fever,  280 
in  sepsis  in  newborn,  201,  205 
summer,  517 
Diastase  in  artificial  infant  foods.  119 


908 


IXDEX. 


Diastase  in  preparation   of  dextrinized 

grueJ.  158 
Diastased  farina.  121 
Diatheses,  hemorrhagic.  747 

transmission    of.    bv    Tret-nursing, 
122.  123 
Diazo    reaction.    Ehrlich  "s.    in    tvphoid 

fever.  331 
Dicrotism,  30 
Diet  after  operations.  164 
articles  of,  to  avoid,  162 
during  convalescence,  164 
infantile  scorbutus  and,  2.55 
in  rachitis.  247 
in  sick  infants.  164 
Dietaries  for  infants  and  children.  162, 

163 
Diffuse  nephritis,  acute,  776,  777 

chronic,  781 
Digestive  functions  in  nevrborn,  169 
Dilatation  of  heart,  709 

of  stomach.  509 
Diphtheria.  378 
age  and.  378 
antitoxin  in.  397 
dosage  of.  397 
effect  of.  398 

on  blood,  399 
on  kidneys,  399 
on  temperature,  399 
eruptions  after.  399 
injection  of.  method  of.  398 
bacillus  of.  379 
blood  in,  384 

bronchopneumonia  and,  388,  640 
catarrhal.  384 
complications  of.  388 
contagion  of,  379 
coarse  of,  388 
diagnosis  of.  394 

from  aphthae,  395 
from  catarrhal  laryngitis,  593 
from  diphtheroid.  394 
from  herpes  of  fauces.  395 
from     larvngismus      stridulus, 

394 
from  stomatitis.  394 
from  traumatic  sorethroat,  396 
disinfection  in.  396 
duration  of,  388 
endocarditis  and,  690 
erythema  urticatum  in,  393 
etiology  of,  379 
exanthema  of,  393 
false,  410.     See  also  Diphtheroid 
fibrinous  bronchitis  and.  600 
forms  of,  384 
gastroenteritis  and,  389 
heart  in,  382 
human  milk  and,  97,  98 
incubation  of,  379 
from  infected  cows'  milk,  105 
infection  in,  380 
intubation  in,  402 
dangers  of,  408 
extubation  in,  408 


Diphtheria,  intubation  in,  feeding  in,  409 

indications  for,  402 

instruments  for,  402 

method  of.  402 

O  'Dwyer  's  tubes  in,  402 
kidneys  in.  388 
laryngeal,  387 

treatment  of,  401 
liver  in.  383 
localized  forms  of,  384 
lungs  in,  382 
lymph-nodes  in.  383.  385 
measles  and,  301.  309,  396 
melancholia  in,  392 
membrane  of,  382,  394 
middle  ear  in,  383 
muscular  atrophy  in.  49 
myocarditis  and,  707 
of  nasal  pjassages.  393 
nephritis  and.  389 
nerves  in.  383 
occurrence  of,  378 
ophthalmia  and.  392 
paralysis  and,  391 

cardiac.  390 

of  soft  palate  in.  395 

treatment  of,  409 
pathology  of.  381 
pertussis  convulsiva  and,  393 
pleuritis  and,  388 
prognosis  of,  396 
prophylaxis  of.  396 
pseudobacillus  of,  380 
retropharyngeal  abscess  and.  389 
in  scarlet  fever,  270 
sensory  nei'ves  in,  392 
septic,  385 
sex  and.  379 
sine  membrana,  384 
of  skin.  392 
spleen  in.  383 
stomach  in.  383 
symptoms  of.  384 
thvmus  gland  and,  729 
toxins  of.  380 
treatment  of,  396 

constitutional,  397 

local.  401 
in  typhoid  fever,  328 
ulcers  of,  diagnosis  of,  from  ulcero- 
membranous tonsillitis,  592 
of  vulva.  392 

treatment  of.  409 
Diphtheritic  ophthalmia,  392 
paralysis.  391 

cardiac,  390 
rhinitis,  578 
Diphtheroid.  410 

diagnosis  of.  410 

from  diphtheria,  394 
etiology  of.  410 
in  scarlet  fever,  270 
symptoms  of,  410 
treatment  of,  411 
Diplegia.  843 

cerebral.  843 


INDEX. 


909 


DiplococcLis    intracellularis    in    cerebro- 
spinal meningitis,  347 
pneumoniae  in  cerebrospinal  menin- 
gitis, 348 
Dirt-eating,  805 
Diverticula  of  oesophagus,  488 
Dropsy  of  brain,  833 
Drugs,  administration  of,  63 
antipyretic,  63,  64 
cautions  concerning,  62,  63 
dosage  of,  64 

eruptions    of,    diagnosis    of,    from 
measles,  307 
from  scarlet  fever,  282 
in  human  milk,  97 
Dry  pleurisy,  650 
Ductus  arteriosus,  closure  of,  167 

in    congenitally   weak   infants, 

184 
open,  686,  687,  689 
murmur  in,  689 
physical  signs  of,  689 
right  ventricle  in,  689 
Botalli.     See  Ductus  arteriosus 
disease,  689 
Dulness,  normal,  in  percussion,  612 
Dusting-powder,  61 
Dwarfism,  726 

differentiation    of,    from    infantil- 
ism, 726 
with     idiocy,     diagnosis    of,     from 
sporadic  cretinism,  725 
Dwarfs,  727 

Dyscrasias,  constitutional,  melsena  neo- 
natorum in,  220 
Dysentery,  528 

acute  nephritis  and,  778 
amoebic,  534 

C'harcot-Leyden  crystals  in,  534 
diagnosis  of,  534 
etiology  of,  534 
treatment  of,  535 
arthritis  in,  532 
bacteriology  of,  529 
complications  of,  532 
diagnosis  of,  from  intussusception, 

545 
diet  in,  533 

enemata  in,  rectal,  533 
•    etiology  of,  529 
forms  of,  529 

from  infected  cows'  milk,  105 
intestinal  perforation  in,  532 
pathology  of,  530 
periproctitic  abscess  in,  532 
i:)eritonitis  in,  532 
jsrognosis  of,  532 
prophylaxis  of,  532 
serum  for,  534 
symptoms  of,  530 
treatment  of,  532 
Dyspepsia,  acute  gastric,  502 

symptoms  of,  502 
treatment  of,  502 
infant  foods  in,  use  of,  157 
Dyspnoea  in  abdominal  tumors,  615 


Dyspnoea  in  ascites,  615 

in  asthma,  614 

in  atelectasis,  199  ' 

in  bronchiectasis,  609 

in  bronchopneumonia,  634 

cardiac,  614 

in  chronic  valvular  disease  of  heart, 
703 

in  dilatation  of  heart,  709 

in  emphysema  of  lungs,  604,  605 

in  fever,  614 

in  fibrinous  bronchitis,  601 

forms  of,  614 

laryngeal,  614 

in  lobar  pneumonia,  618,  622 

in  myocarditis,  708 

in  pain,  614 

in  pericarditis,  676 

pulmonary,  614 
Dysuria,  773 

cellular  atresia  of  labia  and,  773 

treatment  of,  773 


Ear,  diseases  of,  759 

examination  of,  762 
Echolalia  in  tic,  832 
Echymoses  in  infantile  scorbutus,  257 
Eclampsia,  acetone  in  urine  in,  33 
infantum,  797 
in  scarlet  fever,  279 
Ecthyma  in  scrofulosis,  413 
Ectopia  testis  abdominalis,  181 
cruralis,  182 
perinealis,  182 
Eczema,  884 

etiology  of,  886 
forms  of,  885 
impetiginous,   885 
intertrigo,   885 

pustular,  885 
in  scrofulosis,  413 
seborrhoeic,  886 
treatment  of,  887 
vaccination  and,  317 
vesicular,  885 
Effusion,   restriction    of   movements   of 

chest  in,  611 
Ehrlich  diazo  reaction  in  typhoid  fever, 

331 
Elastin,  84 
Electric  chorea,  822 

stimulation    and   reactions   in   new- 
born, 175 
Emphysema  of  lungs,  601 
adenoids  in,  602 
asthma  in,  604 
'  auscultation  in,  603,  605 

chest  in,  deformity  of,  602,  604 
chronic  bronchitis  in,  601,  602 
dyspnoea  in,  604,  605 

spasmodic,  604 
enlarged  tonsils  in,  602 
inspection  in,  604 
lymphatism  and,  602 


910 


INDEX. 


Emphysema  of  lungs,  palpation  in,  603, 
605 
■    pathology  of,  602 

percussion  in,  603,  605 

physical  signs  of,  603 

prognosis  of.  606 

rachitis  and,  602 

restriction    of    movements    of 
chest  in,  611 

symptoms  of,  602 

thorax  in,  602 

treatment  of,  606 

vesicular,  602 
Empyema,  650,  652 
adhesions  in,  671 
age  and,  652 
appendicitis  and,  652 
aspirator  for,  Potain  's,  667 
auscultation  in,  658,  661 
bacteriology  of,  653,  654 
bilateral,  671 

prognosis  of,  672 

treatment  of,  672 
bronchiectasis  and,  609 
bronchophony  in,  662 
bronchopneumonia  and,  652 
diagnosis  of,  657 

fluid  in,  662 
etiology  of,  652 
exploratory  puncture  in,  663 
exudate  in,  653 
heart  in,  displacement  of,  662 
hemorrhagic,  672 
infectious  diseases  and,  652 
inspection  in.  658,  659,  660 
liver  in,  displacement  of,  662 
lobar  pneumonia  and,  627,  628,  652 
metapneumonic,  657 
onset  of,  656 

palpation  in,  658,  659,  660 
pathology  of,  653 
percussion  in,  658,  659,  660 
perforating,  664 
physical  signs  of,  657 
pleural    fold    in,    displacement    of, 

661 
pleuritic  crepitations  in,  660 
primary,  652 

puncture  in,  exploratory,  663 
in  scarlet  fever,  276 
secondary,  652 

simulating  enlargement  of  liver,  562 
skodaic  resonance  in,  659 
suppurating  sinus  in  persistent,  670 
symptoms  of,  656 
temperature  in,  656 
termination  of,  665 
treatment  of,  666,  667,  668,  669 

operative,  669,  670 
tuberculous,  666 
viscera  in,  displacement  of,  662 
Encephalitis,  acute,  859 

aphasia  in,  860 

etiology  of,  859 

hemorrhagic  cortical,   859 

Kernig's  symptom  in,  860 


Encephalitis,     acute,    lumbar    puncture 
in,  861 

meningitis  and,  860 

neck-rigidity  in,  860 

paralysis  in,  860,  861 

pathology  of,  859,  860 

prognosis  of,  861 

symptoms  of,  860 

tache  cerebrale  in,  860 

treatment  of,  861 
Eucephalocele,  880 
Endocarditis,  690 
acute,  690 
acute     articular    rheumatism     and, 

461,   690 
auscultation  in,  694 
bacterial  invasion  in,  692 
bacteriology  of,  690 
cerebrospinal  meningitis  and,  690 
chorea  and,  690,  693,  826 
diphtheria  and,  690 
in  erythema  multiforme,  891 

nodosum  and,  690 
etiology  of,  690 
fever  in,  692 

in  follicular  amygdalitis,  590 
gonococcus  in,  691 
heart-action  in,  695 
influenza  and,  341,  690 
inspection  in,  694 
location  of,  690 
malignant,  696 
measles  and,  303,  690 
modes  of  infection  in,  691 
murmurs  in,  694 
osteomyelitis  and,  690 
palpation  in,  694 
pathology  of,  691 
percussion  in,  694 
pericarditis  and,  692 
physical  signs  of,  694 
pneumonia  and,  690 
polyposa,  691  / 

prognosis  of,  695 
pustulosa,  692 
recurrent,  694 

chronic,  699 
rheumatism  and,  693 
scarlet  fever  and,  279,  690 
sepsis  and,  690 
septic,  696 

blood  in,  698 

Cheyne-Stokes    respiration    in, 
698 

diagnosis  of,  699 

dilatation  of  ventricle  in,  698 

forms  of,  696 

murmurs  in,  698 

petechia;  in,  698 

prognosis  of,  699 

symptoms  of,  698 

treatment  of,  699 
symptoms  of,  692 
temperature  in,  693 
tonsillitis  and,  466 
tonsils  in,  infection  through,  691 


INDEX. 


911 


Endocarditis,  toxins  in,  691 
treatment  of,  695 
tuberculosis  and,  690 
typhoid  fever  and,  690 
ulcerosa,  692 
ulcerative,  696 
valvular  vegetations  in,  692 
verrucosa,  691 
Endemic  cretinism,  718 
Enemata  in  nephritis,  73 
nutritive,  74 
oil,  74 

in  pyloric  spasm,  517 
rectal,  72 

in   acute   gastro-enteric    infec- 
tion, 525 
in  dysentery,  533 
in  typhoid  fever,  73 
in  vomiting,  uncontrollable,  74 
Enlargement  of  spleen,  733 
Enteratomata  of  umbilicus,  207 
Enteric  catarrh,  527 

Enteritis,    diagnosis    of,    from    typhoid 
fever,  330 
foUicularis,  527,  528 
Enteroclysis,  72 
Enterocolitis,  527 
etiology,  527 
pathology  of,  527 
symptoms  of,  528 
treatment  of,  528 
Enuresis  diurna,  789 
nocturna,  789 

diagnosis  of,  789 
etiology,  789 
symptoms  of,  789 
treatment  of,  789 
Enzymes  in  human  milk,  88,  89,  94 
Epidemic  cerebrospinal  m.eningitis,  348 
chorea,  822 
hysteria,  804 

parotitis,  368.     See  also  Mumps 
poliomyelitis,  861 
Epididymis,    metastasis    of    mumps    to, 

371 
Epilepsy,  819 
aura  in,  820 
chorea  and,  825 
convulsions. in,  820 
diagnosis  of,  821 

from  hysteria,  821 
from    post-hemiplegic    convul- 
sions, 821 
from  syncope,  821 
from  tumor  of  brain,  821 
etiology  of,  820 
forms  of,  820 
heredity  and,  820 
in  infantile  cerebral  palsy,  845,  849 
infantile  palsy  and,  820 
pavor  nocturnus  and,  822 
symptoms  of,  820 
treatment  of,  821 
Epileptic  form  of  idiocy,  878 
Epistaxis,  579 

loss  of  blood  in,  quantity  of,  579 


Epistaxis,  symptoms  of,  579 
Epithelium,  exfoliated,  in  otitis,  764 
Epstein's  pearls,  203 
Erb's  palsy,  857 

type  of  progressive  muscular  atro- 
phy,  872 
Eruption  in  scarlet  fever,  271 
Erysipelas  of  umbilicus,  209 
Erythema  exudativum,  890 

cardiac  disease  in,  891 
intertrigo,  885 
multiforme,  890 

endocarditis  in,  891 
treatment  of,  891 
nodosum,  466,  890 

endocarditis  and,  690,  691 
symptoms  of,  890 
treatment  of,  891 
Erythrocytes,  734 

in  newborn,  169 
Escherich's  method  of  artificial  infant- 
feeding,  135 
Eskay's  food,  121 
Essential  paralysis  of  children,  861 
Exanthemata,  265 

Exanthematic   fevers,   acetone   in   urine 
in,  33 
diacetic  acid  in  urine  in,  34 
Excitement,  rapidity  of  pulse  during,  30 
Excreta,  calculation  of  calories  from,  87 
Excretion  in  newborn,  177 
External  cephalohajmatoma,  234 

hydrocephalus,  836 
Exudative  nephritis,  acute,  776,  777 
Eye  reflexes  in  newborn,  176 
Eyes  in  newborn,  55 

cleansing  of,  55,  56 


Face,  expression  of,  in  adenitis,  39 

in  adenoids,  39 

in  Basedow's  disease,  39 
■     in  cardiac  disease,  39 

in  congenital  syphilis,  40 

in  diarrhoea,  39 

in  exhausting  diseases,  39 

in  facial  paralysis,  39 

hydrencephaloid,  40 

in  hydrocephalus,  39 

in  Mongolian  idiocy,  40 

in  mouth-breathing,  39 

in  nuclear  palsy,  39 

in  parotiditis,  39 

in  rachitis,  39 

in  respiratory  disorders,  39 

in  sleep,  normal,  39 
protection  of,  in  open  air,  60 

against  sun's  rays,  60 
Facial  palsy,  851 

Facio-scapulo-humeral    type    of    muscu- 
lar atrophy,  873 
Fasces,  examination  of,  38 
Fairchild's  panopeptone,  116 
Family  idiocy,  837 
.  Fat,  in  artificial  infant  foods,  121 


912 


INDEX. 


Fat  in  infant-feeding,  137 
calories  in,  S7 
in  cows'  milk.  102,  103 
diarrhoBa,  S4 

in  artificial  infant -feeding,  153 
digestion  of,  in  newborn,  169 
estimation  of.  in  human  milk.  100 
Lewi's  method  of,  100,  101 
Soxhlet  's  quantitative,  101 
in  human  milk,  93 
percentage  of,  in  cows'  milk,  84 
in  human  milk,  S4 
low,  154 
role  of.  in  nutrition,  84 
Fat-sclerema,  226 
Fatty  acids  in  human  milk,  93 

degeneration,    acute,    of    newborn, 
221 
of  liver,  565 

true  omphalorrhagia  in,  212 
I'eeding.  artificial,  of  congenitally  weak 
infants,  191 
mortalitv  and,  18 
breast,    of    congenitally    weak    in- 
fants, 190 
infant-,  81 

of  infants.     See  Infant-feeding 
mixed,    of    congenitally    weak    in- 
fants, 192 
Ferments,  amylolytic,  in  newborn,  169 

in  human  milk,  94 
Fever,  ataxic  gait  after,  50 
cardiac  murmurs  in,  705 
in  onset  of  illness.  37 
sponge  bath  in,  65 
typhoid,  31S 
Fibrinous  bronchitis,  600 
pericarditis,  674 
pneumonia,  615 
FUth  infections,  IS 
Finger-nails,  biting  of,  806 
Fissure  of  anus.  553 

fjalpebral,  examination  of,  40 
Fissured  nipples,  128 
Flexner's  serum  in  cerebrospinal  men- 
ingitis, 360 
in   posterior   basic   meningitis, 
366 
Floating  kidney,  45,  770 
Fluid,  cerebrospinal.      See  Cerebrospinal 
fluid 
free,  in  abdomen,  44 
Fa?tal  rachitis,  237 
rickets,  250 
tuberculous,  419 
typhoid  fever,  319 
Follicular  amygdalitis,  589 
Folliculitis  abscedens,  891 
Fontanelles,  26,  27 

closure  of,  time  of,  27 

delay  of,  in  rachitis,  27 
premature    closure    of,    in    miero- 
cephalus,  38 
Food,  effect  of,  on  human  milk,  96 

infant,  use  of,  indications  for,  157 
preparations,  112 


Foot,    deformities    of.   in   spina   bifida, 

881 
Foramen  ovale,  open,  689 
Foreign  bodies  in  larynx,  597 
Fragilitas  ossium  idiopathica,  252 
Freeman's  nursing  bottle,  111 

pasteurizer,  106,  107 
Fremitus  in  chest,  611 
Friedreich's  disease,  858.     See  Ataxia, 

hereditary 
Frontal  lobe,  tumors  of,  841 
Frozen  milk,  111 
Fungus  of  umbilical  cord,  53 

of  umbilicus,  207 
Funnel,  Quincke,  81 
Furuncles  in  diabetes  mellitus,  712 
Furunculosis,  891 

symptoms  of,  891 

treatment  of,  891 

G 

Gait,  ataxic,  50 

in  cerebral  disease,  50 

tumor,  50 
in  diphtheritic  paralysis,  50 
in  Friedreich's  ataxia,  50 
after  fevers,  50 
in    pseudohypertrophic    paral- 
ysis, 50 
limping,  51 

in  infantile  paralysis,  51 
in      pseudohypertrophic      muscular 

paralysis,  874 
spastic,  51 

in  spastic  paraplegia,  51 
in  young  infants,  51 
Gallop-rhythm  in  myocarditis,  708 
Gangrene  of  the  lungs  in  bronchiecta- 
sis, 609,  610 
in  scarlet  fever,  280 
in  typhoid  fever,  328 
of  pinna  in  measles,  305 
in  scarlet  fever,  272 
of  umbilical  cord,  53 
of  umbilicus,  208 
Gangrenous  acute  appendicitis,  549 
Gastric  dyspepsia,  acute,  502 

spasm,  congenital,  512 
Gastro-enteric   disturbances,  barley  wa- 
ter in,  114 
infection,  acute,  517 

albuminuria  in,  520 
bacteriology  of,  518,  519 
baths  in,  525 
classification  of,  518 
colic  in,  521,  526 
diarrhoea  in,  520,  524 
diet  in,  524 
etiology  of,  518 
hypodermoclysis  in,  525 
intestines  in,  519 
kidneys  in,  519 
liver  in,  519 
lymph-nodes  in,  519 
pathologj'  of,  519 


INDEX. 


913 


Gastro-enteric    infection,     acute,    prog- 
nosis in,  521 
prophylaxis  of,  523 
rectal  enemata  in,  525 
stomach  in,  519 
symptoms  of,  520 
treatment  of,  523 

medicinal,  526 
vomiting  in,  520,  524 
Gastro-enteritis,  517.     See  also  Gastro- 
enteric infection,  acute 
acute  nephritis  and,  778 
administration  of  water  in,  83 
condensed  milk  in,  113,  114 
diphtheria  and,  389 
indican  in  urine  in,  33 
in  pertussis  convulsiva,  376 
tympanitis  in,  45 
Gastro-intestinal  tract,  diseases  of,  493 
Gavage,  71,  72 

in  congenitally  weak  infants,  189 
in  pneumonia,  71 
in  typhoid  fever,  71 
Genitalia,  care  of,  57,  58 
in  females,  58 
in  males,  58 
powdering  of,  58 
Genetous  idiocy,  877 
Geographical  tongue,  486 
German  measles,  291.     See  Kotheln 
Glandular  fever,  345 

diagnosis  of,  346 
duration  of,  346 
etiology  of,  345 
lymph-nodes  in,  345 
symptoms  of,  345 
treatment  of,  346 
Globus  hystericus  in  hysteria,  803 
Glomerular  nephritis,  776 
Glottis,  oedema  of,  594 

spasm  of,  816 
Glutin,  84 
Glycogen,  85 

Goitre  in  endemic  cretinism,  718 
Gonococcal  peritonitis,  570 
Gonococci  in  vulvovaginitis,  791 
Gonorrhoeal  infection  of  mouth,  482 
ophthalmia,  55,  56,  228 
proctitis,  554 
rheumatism,  466 
Grand  mal,  820 
Granuloma  of  umbilicus,  207 
Grape  sugar,  85 

Grippe,  399.     See  also  Influenza 
Growths,  adenoid,  579 
Gruel,  arrowroot,  115 
barley,  157 
dextrinized,  158 

preparation  of,  158,  159 
cereo  in,  158,  159 
diastase  in,  158 
oatmeal,  115 

H 

Habits,  bad,  805 
movements,  831 

58 


Habits  in  chorea,  828 

diagnosis  of,  from  chorea,  328 
spasms,  831 
Habitual  vomiting  of  infants,  503 
Hsematoma  of  sternomastoid  muscle,  233 
symptoms  of,  233 
treatment  of,  234 
Ha?maturia,  774 

in  carcinoma  of  kidney,  786 
etiology  of,  774 
in  infantile  scorbutus,  256,  257 
in  sarcoma  of  kidney,  785 
urine  in,  774 
Haemoglobin,  736 
Hsemoglobinuria,  774 

epidemic,    of    newborn,    222.     See 

Winckel's  disease 
etiology  of,  774 
pathology  of,  775 
prognosis  of,  775 
"shadow"  cells  in,  775 
symptoms  of,  775 
treatment  of,  775 
Haemophilia,  219,  748 
etiology  of,  748 
hemorrhages  in,  749 
nature  of,  748 

in  newborn,  hemorrhages  in,  219 
treatment  of,  749 
Haemoptysis  in  bronchiectasis,  609 

in  pulmonary  tuberculosis,  423 
Hallucinations  in  pavor  nocturnus,  822 
Head,  circumference  of,  26 
examination  of,  38 
lymph-nodes  of,  33 
measurements  of,  26 
position  of,  in  amaurotic  idiocy,  35, 
38 
in  birth-paralysis,  38 
in  defective  vision,  40 
in  diphtheritic  paralysis,  38 
in  meningitis,  38 
in  Pott's  disease,  38 
in   spasm   of  cervical  muscles, 

40 
in  torticollis,  38 
in   weakness   of   cervical   mus- 
cles, 40 
power    to    hold    upright,    develop- 
ment of,  35 
rhythmic  movements  of,  nystagmus 
and,  832 
dentition  and,  832 
etiology  of,  832 
rachitis  and,  832 
treatment  of,  833 
rolling  of,  from  side  to  side,  806 
shape  of,  in  craniotabes,  38 
in  rachitis,  38,  240 
Head-banging,  806 
Head-nodding,  806,  832 
Head-swaying,  806 
Hearing,  development  of,  35 

sense  of,  in  newborn,  176 
Heart,  apex-beat  of,  682 
auscultation  in,  683 


914 


INDEX. 


Heart,  congenital  disease  of,  685 

cardiac  dilatation  in,  685 
hypertrophy  in,  685 
cyanosis  in,  685 
diagnosis  of,  686 
murmurs  in,  686 
open  ductus  arteriosus  in, 

686,  687 
pulmonary  artery  in,   636 
septal  defects  in,  686 
stenosis  of  aortic  valve  in, 

686 
transposition  of  heart  in, 

687 
valvular  anomalies  in,  687 
ventricular        hypertrophy 
in,  686 
dilatation  of,  709 

in  congenital  disease  of  heart, 

685 
dyspnoea  in,  709 
infectious  diseases  and,  709 
sudden  death  in,  709 
symptoms  of,  709 
transudates  in,  709 
treatment  of,  710 
disease  of,  682 

contra-indication    to    maternal 

nursing,  124 
in  erythema  exudativum,  890 
nodosum,  891 
displacement  of,  in  empyema,  662 
dulness  in,  marking  of,  683 
hypertrophy  of,  709 

arteriosclerosis  and,  709 

in  congenital  diseases  of  heart, 

685 
symptoms  of,  709 
treatment  of,  710 
inspection  of,  682 
irritable,  700,  701 
palpation  of,  683 
percussion  in,  683 
position  of,  682 
praecordium  of,  682 
size  of,  682 
transposition  of,  687 
tuberculosis  of,  432 
valvular  disease  of,  chronic,  699 
angina  in,  703 
cardiac      insufficiency 

in,  700 
dyspnosa  in,  703 
etiology  of,  699 
myocarditis  and,  708 
pallor  in,  701 
palpitation  in,  701 
physical  signs  of,  700 
prognosis  of,  703 
treatment  of,  703 
rheumatic     pains     in, 
700 
ventricles  of,  location  of,  684 
Heat  calories,  31 

sense  in  newljorn,  177 


Hemiplegia  in  infantile  cerebral  palsy, 
846 
spastic,  843,  845.     See  also  Palsy, 
cerebral,  infantile 
Hemorrhage   in    acute   fatty    degenera- 
tion of  newborn,  222 
cerebral,    diagnosis    of,    from    as- 
phyxia in  newborn,  195 
in  newborn,  219 
in  Buhl's  disease,  219,  222 
in  sepsis,  219 
in  haemophilia,  219 
syphilitic,  219 

in  Winckel  's  disease;  219,  223 
sudden  death  in  newborn  and,  180 
Hemorrhagic    conditions    in    sepsis    in 
newborn,  201 
cortical  encephalitis,  acute,  859 
diatheses,  747 
empyema,  672 
periostitis,  254 
pleurisy,  672 
rachitis,  237,  254 
Hennig's  symptom,  210 
Henoch 's  purpura,  752 
Hepatitis,  suppurative,  566 
Hepatization  in  lobar  pneumonia,  616 
Hereditary  syphilis,  448 
ataxia,  858 

ataxic  paraplegia,  858 
Hernia    of    brain,    diagnosis    of,    from 
cephaloh^matoma,  235 
diagnosis   of,   from  hydrocele   con- 
genita, 183 
from  retention  of  testicle,  182 
umbilical,  213 

etiology  of,  213 
treatment  of,  213 
Herpes  in  cerebrospinal  meningitis,  356 
of  fauces,  diagnosis  of,  from  diph- 
theria, 395 
of  tonsils,  591 
Hetero-infection  in   sepsis   in   newborn, 

201 
Hirschsprung's  disease,  540 
History,  maternal,  36 
parental,  37 
taking,  36 
Hochsinger's   induration   in    hereditary 

syphilis,  453 
Hodgkin's  disease,  747 

diagnosis   of,    from   ]euka?mia, 
747 
from  tuberculous  adenitis, 
747 
lymph-nodes     in,     enlnrgement 
of,  747 
Hook-worm  disease,  558 
Horner's  symptom,  40 
Huebner-Hoffman    method    of   artificial 

infant-feeding,  135 
Hum,  venous,  706 
Human  milk.     See  Milk,  human 
Huntington 's  chorea,  823 
Hutchinson's  teeth  in  syphilis,  471 
Hydnemia  without  kidney  lesion,  773 


INDEX. 


915 


Hydrsemia  in  simple  aiiEemia,  737 
Hydrenceijhaloid,     diagnosis    of,     from 
congenital    internal    hydrocepha- 
lus, 834 
expression  of  face,  40 
Hydrocele  adnata,  182 
congenita,  182 

diagnosis  of,  183 

from  hernia,  183 
treatment  of,  183 
Hydrochloric  acid,  decrease  of,  rachitis 
and,  238 
in  newborn,  169 
Hydrocephalic  form  of  idiocy,  878 
Hydrocephalus,  833 

acquired,    diagnosis    of,   from   con- 
genital   internal     hydrocephalus, 
835 
acute  internal,  366,  432 
chronic,  cerebrospinal  fluid  in,  76 
lumbar  puncture  in,  78 
diagnosis     of,     from     rachitis, 
246 
external,  836 

diagnosis  of,  837 

from    congenital    internal 
hydrocephalus,  835 
etiology  of,  836 
pachymeningitis  and,  836 
facial  expression  in,  39 
internal,  congenital,   833 

cranial  bones  in,  834 
craniotabes  in,  834 
diagnosis  of,  834 

from  acquired  hydro- 
cephalus,  835 
from  cranial  syphilis, 

835 
from   external   hydro- 
cephalus, 835 
from        hydrencepha- 

loid,  834 
from  rachitis,  834 
etiology  of,  833 
fontanelles  in,  834 
idiocy  in,  833 
paralysis  in,  833 
pathology  of,  833 
prognosis  of,  835 
symptoms  of,  833 
treatment  of,  835 
in  rachitis,  240,  245 
Hydromyelocele,  881 
Hydronephrosis,  784 

diagnosis    of,    from    carcinoma    of 
kidney,  787 
from  cyst  of  kidney,  785 
Hydrorrhachis,  880 
Hydrotherapy,  64 

Hypersesthesia   in   cerebrospinal   menin- 
gitis, 352 
Hyperthermia,  sudden  death  and,  21 
Hypertrophy  of  heart,  709 
muscular,  49 

in     pseudohypertrophic     paral- 
ysis, 49 


Hypertrophy  of  thymus  gland,  728 
thymus  death  in,  731 
Hypodermic  administration  of  drugs,  64 
Hypodermoclysis,  66 

in    acute    gastro-enteric    infection, 
525 

in  cholera  infantum,  66 
Hysteria,  802 

anaesthesia  in,  804 

anorexia  in,  804 

bradycardia  in,  805 

catalepsy  in,  803 

contortions  in,  803 

convulsive  forms  of,  803 

dancing  mania  in,  804 

diagnosis  of,  805 

from  epilepsy,  821 
from    tuberculous    meningitis, 
805 

disturbances  of  sensation  in,  804 
of  vision  in,  804 

epidemics  of,  804 

etiology  of,  802 

globus  hystericus  in,  803 

hyperesthesia  in,  804 

hystero-epilepsy  in,  803 

mental,  802 

motor  manifestations  in,  803 

non-convulsive,  802 

onset  of,  803 

paralyses  in,  804 

psychic,  802 

sex  and,  802 

sexual  organs  in,  abnormalities  of, 
802 

symptoms  of,  802 

tachycardia  in,  804 

treatment  of,  805 
Hystero-epilepsy  and  hysteria,  803 


Ichthyosis,  congenital,  893 
symptoms  of,  894 
treatment  of,  894 
Icterus,  catarrhal,  563 

gravis  in  newborn,  218 

infectious,  563 

neonatorum,  217 

etiology  of,  218 
symptoms  of,  218 
treatment   of,  218 

in  newborn,  217 

in  sepsis  of  newborn,  217 

simple,  563 
Idiocy,  876 

amaurotic,  837 

deep  reflexes  in,  839 
diagnosis  of,  839 
etiology  of,  837 
juvenile  form  of,  839 
nystagmus  in,  40 
ocular  changes  in,  839 
optic  neuritis  in,  839 
paralysis  in,  838,  839 
pathology  of,  838 


916 


INDEX. 


Idiocy,  amaurotic,  position  of  head  in, 
35,  38 
prognosis  of,  840 
spastic  phenomena  in,  51 
symptoms  of,  838 
Tay-Kingdon 's  spot  in,  839 
in    congenital   internal    hydroceph- 
alus, 833 
cretinic  form  of,  878 
epileptic  form  of,  878 
etiology  of,  876 
facies  in.  878 
family,  837 
genetous,  877 

hydrocephalic  form  of,  878 
management  of,  879 
microcephalic  form  of,  877 
Mongolian,      diagnosis      of,      from 
rachitis,  246 
from    sporadic    cretinism, 
724 
facial  expression  in,  40 
palpebral  fissure  in,  40 
paralytic  form  of,  878 
patellar  reflex  in,  49 
predisposition  toward,  876 
sclerotic  form  of,  878 
sj'mptoms  of,  878 
sj'philitic  form  of,  878 
treatment  of,  879 
Idiopathic  hemorrhage  from  umbilicus, 

212.     See  also  Omphalorrhagia,  true 
Ileocolitis,  528 

Ileotyphus,  318.     See  Typhoid  fever 
Imperial  granum,  121 
Impetiginous  eczema,  885 
Incubator,  186 

cleansing  of.  186 
indications  for  use  of,  188 
infections  due  to,  186 
Lion's,  187 
Tarnier's,  186 
temperature  in,  188 
Indican  in  urine,  33 
Indigestion,  502 
Infancy,  convulsions  in,  797 

definition  of,  17 
Infant-feeding,  81 
artificial.  133 

Biedert's  mixture.  133.  134 

Chapin's  method  of,  158 

colic  in,  152.  153 

constipation  in,  152 

dextrin jzed  gruels  in,  158,  159 

diluents  in.  149 

from  eighteenth  month  to  end 

of  second  year,  162 
Escherich 's  method,  135 
fat  diarrhoea  in,  153 
fat-percentages    in,    too    high, 

148 
fats  in,  percentage  of,  137 
formula?  for,  147 
greenish  movements  in,  153 
Huebner-IIoffman    method    of, 
135 


Infant-feeding,        artificial,        Keller's 
method   of,   159 
laboratory  method  of,  133,  135 
Liebig's  formula  in,  159 
lime-water  in,  149 
low  percentage  of  fats  in,  154 

of  proteids  in,  154 
malt  extract  in,  159 
Meigs'  mixture  for,  133,  134 
miJk  in,  home  modification  of, 
140 
quantity  of,  138,  139,  140 
milk  in,  raw,  110 
mixed,   132 
from  ninth  to   twelfth  month, 

160 
nursings  in,  frequency  of,  138, 

139,  140 
over-feeding  in,  132 
peptonization  in,  154,  155 
percentage  method  of,  135, 136 

schedule  for,  138 
percentages  in   calculation   of, 

143.  144 
principles  underlying,  81 
proteids  in,  percentage  of,  137 
Eotch's  method  of,  133,  135 
salts  in,  percentage  of,  131 
after  sixth  month,  160 
Soxhlet  method  of,  135 
spitting  in,  152 
sugar  in,  percentage  of,  137 
table  of  feedings  for,  140 
thriving  under,  signs  of,  150 
from     twelfth     to     eighteenth 

month,   161 
vomiting  in,  154 
whey  method  in,  155 
vom.iting  in,  132 
Infant-foods,  artificial,  119,  120,  121 
carbohydrates  in,  119,  121 
classification  of,  119,  120 
composition  of,  120,  121 
diastase  in,  119 
fats  in,  121 
malt  extract  in.  119 
objections  to,  119,  121 
proteids  in,  121 
rachitis  from,  119 
scurvy  from,  119 
sugar  in,  121 

at  time  of  weaning,  121,  122 
use  of,  indications  for,  157 
in  dyspepsia,  157 
in  intestinal  disease,  157 
utility  of,  119 
varieties  of,  119,  120 
Infantile  atrophy,  260 
palsy,  cerebral,  843 
paralysis,  861 
scorbutus,  254 
scurvy,  254 
typhoid  fever,  319 
Infantilism,  dental,  in  syphilis,  473 
diagnosis  of,  from  sporadic  cretin- 
ism, 725 


INDEX. 


917 


Infantilism,     differentiation     of,     from 

dwarfism,  726 
Infants,  artificially  fed,  metabolism  in, 
88 
breast-fed,  metabolism  in,  85,  86 
congenitally  weak,  183 

appearance  of,  184 
asphyxia  in,  198 
atelectasis  in,  184 
bath  of,  190  ' 
bronchial  nodes  in,  184 
bronchitis  in,  189 
bronchopneumonia  in,  184, 

185 
clothing  of,  190 
desquamation  in,  184 
diarrhoea  in,  185 
ductus  Botalli  in,  184 
etiology  of,  183 
feeding  of,  188 
artificial,  191 
breast,  190 
mixed,  192 
with     modified     milk, 

192 
with  peptonized  milk, 
192 
food  of,  amount  of,  192 
gavage  in,  189 
hemorrhages  in,  184 
incubators  for,  186 
infarctions  in,  184 
infections  in,  184 
intestines  in,  184,  185 
meconium  in,  185 
morbid  anatomy  of,  184 
nursing  tube  for,  188 

Breck's,   189,190 
pathology  of,  184 
pericarditis  in,  184 
pneumonia       in,       hemor- 
rhagic, 184 
prematurity  and,  183 
prognosis  of,  185 
sclerema  in,  184 
sepsis  in,  184 
skin  of,  184 
symptoms  of,  184 
syphilis  and,  184 
temperature  in,  185,  186 
triplets  and,  184 
tuberculosis  and,  184 
twins  and,  184 
weight  in,  183,  185 
food  of,  89 
marantic,  feeding  of,  159 

scurvy  in,  159 
premature,  183 
Infarction,  uric  acid,  34,  775 
Infections,  bacillary,  of  human  milk,  97 
in  childhood,  18 
filth,  18 
in  newborn,  17 
otogenic,  202 
urogenital,  202 


Infectious    diseases,   acute,   contra-indi- 
cation  to   maternal  nursing, 
124 
bacteria  of,  in  human  milk^  97 
chorea  and,  824 
muscular  atrophy  in,  49 
specific,  265 
vomiting  in,  507 
icterus,  563 
myelitis,  acute,  756 
Inflammatory  bronchiectasis,  607 
Influenza,  339 
age  and,  340 
albuminuria  in,  344 
bacteriology  of,  340 
bronchitis  in,  342 
bronchopneumonia  in,  341 
cerebrospinal  meningitis  in,  342 
cystitis  and,  793 
diagnosis  of,  344 

from  lobar  pneumonia,  629 
from  measles,  306 
diarrhoea  in,  341 
duration  of,  344 
endocarditis  and,  690 
endocarditis  in,  341 
etiology  of,  340 
eyes  in,  341 
incubation  of,  340 
infection  in,  mode  of,  340 
mumps  and,  372 
myocarditis  in,  341 
in  newborn,  340 
nephritis  in,  341,  348 
otitis  media  in,  344 
pneumonia  in,  342 

lobar,  341 
prognosis  of,  344 
symptoms  of,  341 
temperature  in,  341 
treatment  of,  344 
Inhalations,  calomel,  68 

in  acute  laryngitis,  68 
Intermittent  fever,  334 
Internal  cephalohfematoma,  234 
hydrocephalus,  acute,  366 
acute,  432 
congenital,  833 
Intertrigo,  885 
Intestinal  digestion,  497 
casein  in,  498 
fats  in,  499 
milk  sugar  in,  498 
disturbances  in  childhood,  18 
obstruction,  acute,  542 
vomiting  in,  507 
Intestinal  parasites,  555 
residue,  499 
secretions,  497 
walls,  secretions  of,  498 
Intestines,  diseases  of,  493 

perforation  of,  in  dysentery,  532 
in  typhoid  fever,  328 
Intoxications,  sudden  death  and,  21 
Intra-uterine  rachitis,  237 
Intubation  in  diphtheria,  402 


918 


INDEX. 


Intussusception,  542 

abdomen  in,  44,  45 

acute    acquired    constipation    and, 
536 

diagnosis  of,  545 

from  acute  appendicitis,  545 
from  dysentery,  545 
from  scurvy,  545 

etiology  of,  542 

frequency  of,  542 

hemorrhage  in,  544 

onset  of,  543 

prognosis  of,  545 

rectal  exploration  in,  46 

spontaneous  cure  of,  546 

symptoms  of,  543 

tenesmus  in,  544 

treatment  of,  546 

tumor  in,  544 

varieties  of,  542 

vomiting  in,  543 
Todine  in  human  milk,  97 
Tron  in  human  milk,  93 
Irregularity  of  pulse,  30 
Irrigation,  rectal,  72 
Irritable  heart,  700,  701 


Jaundice,  563 

bacteriology  of,  563 

in    congenital   obstruction    of   bile- 
ducts,  564 

enlargement  of  liver  in,  564 
of  spleen  in,  564 

in  newborn,  171 

occurrence  of,  563 

pathology  of,  563 

in  phlebitis  umbilicalis,  211 

simple,  563 

symptoms  of,  563 

treatment  of,  564 
Joint-crepitus,  46,  47 
Joints,  affections  of,  46,  47 

crepitus  of,  46,  47 

examination  of,  46 

motility  of,  46 

palpation  of,  46 


Keller's   method   of   artificial   infant- 
feeding,  159 
Keratin,  82,  84 
Kernig's  symptom,  50 

in  acute  encephalitis,  860 

in     cerebrospinal     meningitis, 

352 
in  mcningism,  50  • 
in  pneumonia,  50 
in  tuberculous  meningitis,  435, 

439 
in  typhoid  fever,  50 
Kidney,  carcinoma  of,  785 
diagnosis  of,   787 

from  cyst  of  kidney,  787 
from   hydronephrosis,   787 


Kidney,     enlargement     of     kidney     in, 
786 
ha'maturia  in,  786 
symptoms  of,  786 
cysts  of,  784 

diagnosis    of,    from    hydrone- 
phrosis, 785 
diseases  of,  770 
enlargement    of,    in    carcinoma    of 

kidney,  786 
floating,  45,  770 
new  growths  of,  784 
palpation  of,  770 
in  pseudoleukgemic  anaemia,  740 
sarcoma  of,  785 

diagnosis  of,   785 
symptoms  of,  785 
tuberculosis  of,  787 
diagnosis  of,  788 
symptoms  of,  787 
urine  in,  787 
tumors  of,  784 

diagnosis    of,    from    tumor    of 

spleen,  739 
simulating  tumor  of  liver,  562 
treatment  of,  788 
weight  of,  770 
Kissing,  development  of,  36 
Hebs-Loffler     bacillus     in     diphtheritic 

rhinitis,  578 
Koch's  peptone,  116 
Koplik's  spots  in  measles,  298 
Kumyss,  117 


Lab-ferment,    digestive    action    of,    in 

stomach,  496 
Labia,   cellular   atresia   of,   dysuria   in, 

773 
Lactalbumin  in  cows'  milk,  102 

in  human  milk,  84,  92 
Lactic  acid  in  cows'  milk,  102,  103 

increase  of,  rachitis  and,  238 
Lactobutyrometer,  Conrad's,  100 
Lactodeusimeter,  Conrad's,  100 

Quevenne  's,  100 
Lactoglobulin  in  human  milk,  92 
La  Grippe,  339.     See  also  Influenza 
Landouzy  type  of  f  acio-scapulo-humoral 

muscular  atrophy,  873 
Lanugo,  170 
Laryngeal  chorea,  822 
diphtheria,  387 
dyspnoea,  614 
stridor,  816 
Laryngismus  stridulus,  816 
apnoea  in,  817 
complications  of,  819 
craniotabes  and,  817 
diagnosis  of,  818 

from  diphtheria,  394 
etiology  of,  817 
pathology  of,  817 
])rognosis  of,  8L8 
rachitis  and,  817 


INDEX. 


919 


Laryngismus    stridulus,     symptoms     of, 
817 
thymus  in,  enlargement  of,  817 
treatment  of,  819 
Trousseau's     phenomenon     in, 
818 
Laryngitis,    acute,    calomel    inhalations 
in,  68 
vapor  spray  in,  68 
catarrhal,  593 

diagnosis  of,  594 

from  diphtheria,  593,  594 
etiology  of,  593 
prognosis  of,  594 
symptoms  of,  593 
treatment  of,  594 
phlegmonous,  594 
spasmodic,  593 
submucous,  594 
Laryngospasm,  tetany  and,  812 
Larynx,  diseases  of,  593 
foreign  bodies  in,  597 
prognosis  of,  597 
symptoms  of,  597 
treatment  of,  597 
syphilis  of,  596 

diagnosis  of,  596 
prognosis  of,  596 
treatment  of,  596 
tuberculosis  of,  432,  596 

treatment  of,  596 
tumors  of,  596 

symptoms  of,  596 
treatment  of,  597 
varieties  of,  596 
Latent  tetany,  812 
Laughing,  development  of,  35 
Lecithin,  82 

in  human  milk,  92,  93 
Length  of  body,  26 
Lepto-meniugitis,  acute,  363 
diagnosis  of,  364 
etiology  of,  363 
symptoms  of,  364 
Leucocytes,  735 

in  newborn,  169 
Leucocytosis  in  scarlet  fever,  280 
Leukaemia,  743 

blood  in,  changes  in,  744 
bone-marrow  in,  744 
diagnosis  of,  from  Hodgkin  's  dis- 
ease, 747 
enlargement  of  lymph-nodes  in,  716 
etiology  of,  743 
lymphatic,  743 
lymph-nodes  in,  746 
myelogenous,  743 
prognosis  of,  747 
rachitis  and,  743 
sldu  in,  745,  746 
spleen  in,  enlargement  of,  744 
symptoms  of,  in  acute  form,  744 

in  chronic  form,  746 
syphilis  and,  743 
treatment  of,  747 


Leukoeythsemia,  743 

Lewi's   method   of    estimation   of   fats, 

100,  101 
Lichen  scrof  ulosorum  in  scrof  ulosis,  413 
Liebig's  beef -extract,  118 

formula  in  artificial  infant-feeding, 

159 
peptone,  116 
Lime-water  in  artificial  infant-feeding, 

149 
Limping  gait,  51 
Lion's  incubator,  187 
Lip  reflex,  468 

in  newborn,  176 
Lipase,  in  cows'  milk,  94 

in  human  milk,  94 
Liquid  peptonoids,  116 
Lithsemia,  775 
Lithiasis,  38 
Little 's  disease,  843 
Liver,  abscess  of,  566 

etiology  of,  566 
symptoms  of,  566 
treatment  of,  567  ■ 
acute  yellow  atrophy  of,  567 
carbohydrates  in,  85 
cirrhosis  of,  565 
age  and,  565 
enlargement  in,  565 
etiology  of,  565 
pathology  of,  565 
symptoms  of,  565 
diseases  of,  560 

contra-indication    to    maternal 
nursing,  124 
displacement   of,  in  empyema,  662 
dulness  of,  44 
enlargement  of,  562 

in  abscess  of  liver,  566 

in    anaemia    infantum    pseudo- 

leukasmica,  562 
in  cirrhosis  of  liver,  565 
in    congenital    obstruction    of 
bile-ducts,  564 
syphilis,  563 
empyema  simulating,  562 
in  fatty  degeneration  of  liver, 

565 
in  jaundice,  564 

normal    rotation    simulat- 
ing, 561 
in     pseudoleukcemic     anae- 
mia, 740,  741 
in  rachitis,  562 
in  Still's  disease,  563 
subphrenic  abscess  simulating, 
562 
examination  of,  560 
fatty  degeneration  of,  565 
measurements  of,  561 
normal  rotation  of,  simulating  en- 
largement of  liver,  561 
jialpation  of,  560 
parasites  of,  567 
percussion  of,  561 
in  rachitis,  239,  245 


920 


INDEX. 


Liver,  secretions  of,  498 

in  sepsis  in  newborn,  204 
syphilis  of,  565 
tumor  of,  567 

kidney  tumor  simulating,  562 
phantom,  562 
weight  of,  560 
Lobar  pneumonia,  615 
Lobular  pneumonia,  632 
Lordotic  albuminuria,   770 
Lourie,  crescents  of,  89,  90 
Lumbar  puncture,  74 

in  acute  encephalitis,  861 

in      cerebrospinal     meningitis, 

357,  360,  361 
danger  of,  79 

fluid  withdrawn,  amount  of,  79 
in  hydrocephalus,  chronic,  78 
indications  for,  77 
in  meningism,   77 
in  meningitis,  77,  78 
operation  of,  77 
in  pneumonia,  78 
in  sepsis  in  newborn,  205 
in  status  epilepticus,  77 
sudden  death  in,  22 
in  tetanus  of  newborn,  217 
Lungs,  atelectasis  of,  198 

collapse  of,  198.  See  also  Atelectasis 
diseases  of,  610 
emphysema  of,  601 
gangrene  of,  in  bronchiectasis,  609, 
610 
bronchopneumonia  and,  640 
induration  of,  in  lobar  pneumonia, 

617 
limits  of,  normal,  6il 
in  newborn,  166 
size  of,  610 
Lupus  in  scrofulosis,  413 
Lusehka's  tonsil,  580 
Lymph,  carbohydrates  in,  85 
Lymphadenitis,  acute,  716 
chronic,  717 

symptoms  of,  717 
treatment  of,  717 
retropharyngeal,  585 
Lymphadenoma,  747 
Lymphangitis  of  breast,  129 
Lymphatic  leukasmia,  743 
Lymphatism,  adenoid  growths  and,  580 
chorea  and,  823 
chronic  nasal  catarrh  and,  576 
emphysema  of  lungs  and,  602 
enlargement  of  lymph-nodes  in,  715 
sudden  death  and,  22 
thymus  death  and,  729 
gland  and,  729 
Lymph-nodes,  diseases  of,  715 

enlargement  of,  in  adenoids,  715 
in  anajmia,  716 
in  balanitis,  715 
in  congenital  sj'philis,  715 
in  disease  of  ear,  715 

of  scalp,  715 
in  exanthemata,  715 


Lymph-nodes,  enlargement  of,  in  Hodg- 
kin 's  disease,  716 
in  leuksemia,  716 
in  lymphatism,  715 
in  parotitis,  715 
in  rachitis,  716 
in     retropharyngeal     adenitis, 

715 
in  tonsillar  infection,  715 
in  tuberculosis,  715 
in  leukgemia,  746 
in  measles,  304 
in  rachitis,  239 

in    scarlet    fever,    270,    273,    276, 
289 
Lymphosarcomata,  716 

M 

McBuRNEY  's    point   in    acute   appendi- 
citis, 550 
Macewen's   sign  in   cerebrospinal   men- 
ingitis, 353 

in  tuberculous  meningitis,  441 
Macroglossia,  484 

congenita  hypertrophica,  484 

lymphatica,  484 
in  sporadic  cretinism,  722 
Maladie  de  Eoger,  689 
Malarial  fever,  334 

age  and,  335 

blood  in,  336 

diagnosis  of,  337 

etiology  of,  335 

incubation  in,  335 

mosquitoes  and,  335 

onset  of,  336 

parasite  of,  335 

pathology  of,  336 

prognosis  of,  338 

quinine  and,  338,  339 

relapses  in,  337 

symptoms  of,  336 

temperature  in,  337 

treatment  of,  338 
Malignant  disease,  eontra-indication  to 
maternal  nursing,  124 
endocarditis,  696 
purpuric  fever,  347 
Malt-extract  in  artificial  infant-feeding, 

159 
Manhu  infant  food,  120 
Marantic  infants,  sudden   death  in,  20 
Marasmus,  260 
Mastitis  in  newborn,  231 

treatment  of,  232 
Mastoid  disease,  765 

age  and,  765 

course  of,  768 

diagnosis  of,  768 

etiology  of,  765 

exanthemata  and,  766 

facial  palsy  and,  851,  852 

measles  and,  766 

otoscopie   examination   in,   767 

pain  in,  767 


INDEX. 


921 


Mastoid  disease,  physical  signs  of,  767 
prophylaxis  of,  768 
scarlet    fever    and,    273,    276, 

766 
swelling  in,  767 
symptoms  of,  765 
temperature  in,  765,  766 
treatment  of,  768 
tumefaction  in,  767 
typhoid  fever  and,  766 
region,  anatomy  of,  765 
Mastoiditis  in  typhoid  fever,  326 
Masturbation,  807 

treatment  of,  807,  808 
Maternal  nursing,  122 

contra-indications  to,  123 

in    acute     infectious    dis- 
eases, 124 
in  Bright 's  disease,  124 
in  heart  disease,  124 
in  liver  disease,  124 
in  malignant  disease,  124 
in     organic     nervous     dis- 
ease, 124 
in  syphilis,  123 
in  tuberculosis,  123 
Measles,  294 

acute  infectious  osteomyelitis  and, 

757 
amaurosis  in,  304 
atelectasis  and,  302 
blood  in,  304 
bones  in,  304 

bronchitis  and,  302,  308,  309 
bronchopneumonia    and,    302,    308, 

309,  639 
buccal  mucous  membrane  in,  298 
complications  of,  300,  308 

treatment  of,  308 
conjunctivitis  in,  295,  304 
contagiousness  of,  295 
corneal  ulcerations  in,  304 
coryza  in,  294,  295,  296 
cystitis  and,  793 
desquamation  in,  295,  296 
diagnosis  of,  306 

from  antitoxin  eruptions,  307 
from  drug  eruptions,  307 
from  influenza,  306 
from  rotheln,  306 
from  scarlet  fever,  282,  306 
from  syphilitic  roseola,  307 
from  typhoidal  roseola,  307 
diarrhoea  in,  303,  310 
diphtheria  and,  301,  309,  396 
ear  in,  305 
enanthema  in,  298 
endocarditis  and,  303,  690 
eruption  in,  296 
exanthema  in,  296,  300 
eyes  in,  309,  310 
firstborn  and,  294 
foetus  and,  294 
gangrene  of  pinna  in,  305 
genitals  in,  305 
German,  291.     See  Eotheln 


Measles,  heart  in,  303 

immunity  from,  294 

incubation  of,  294 

intestines  in,  303 

joints  in,  304 

kidneys  in,  304 

Koplik's  spots  in,  298 

larynx  in,  301,  309     . 

lymph-nodes  in,  304 

mastoid  disease  and,  766 

meningitis  and,  cerebrospinal,  304 

mouth  in,  298,  305,  310 

mumps  and,  372 

myocarditis  in,  303 

nephritis  in,  304 

nervous  system  in,  304 

neuritis  and,  304 

newborn  and,  294 

noma  in,  305 

nose  in,  300,  310 

otitis  in,  305 

pericarditis  in,  303 

pertussis  in,  305 

pharynx  in,  300,  301 

photophobia  in,  296,  304 

pneumonia  and,  301,  302 

prognosis  of,  305 

prophylaxis  of,  307 

sequelae  of,  305 

stomatitis  in,  305 

symptoms  of,  295 

temperature  in,  296 

treatment  of,  308 
Meconium,  174 

analysis  of,  chemical,  175 

bacteria  in,  175 

bilirubin  in,  174 

bodies,  174,  175 

color  of,  174 

composition  of,  174 

in  congenitally  weak  infants,  185 

consistency  of,  174 

odor  of,  174 

plug,  174 

quantity  of,  174 
Medulla,  tumors  of,  843 
Meigs'  mixture,  133,  134 
Melsena  neonatorum,  219 

bacillary  infection  and,  220 
diagnosis  of,  221 
etiology  of,  219 
pathology  of,  220 
prognosis  of,  221 
symptoms  of,  220 
treatment  of,  221 
Melancholia  in  diphtheria,  392 

in  lobar  pneumonia,  623 

pertussis  convulsiva  and,  376 

in  scarlet  fever,  279 
Mellin's  food,  120 
Memory,  development  of,  36 
Meningism,  Kernig's  symptom  in,  50 

lumbar  puncture  in,  77 
Meningitis,  309 

acute  encephalitis  and,  860 

basilar,  432 


922 


INDEX. 


Meningitis,  boat-shaped  abdomen  in,  41 
bronchopneumonia  and,  642 
cerebrospinal,  347 
age  and,  349 
Babinski  reflex  in,  352 
bacteriology  of,  357 
blood  in,  354 
complications  of,  356 
cytology  of,  357 
diagnosis  of,  358 

from    acute    poliomyelitis, 
871 

from     meningitis     serosa, 
368 

from  pneumonia,  359 

from  tetanus  of  newborn, 
216 

from    tuberculous    menin- 
gitis, 358 

from  typhoid  fever,  358 
diet  in,  362 

diplococcus    intracellularis    in, 
347 

pneumoniae  in,  348 
ear  in,  356 
ecchymoses  in,  350 
endocarditis  and,  690 
epidemic,  348 

cerebrospinal   fluid   in,    76 
etiology  of,  347 
eyes  in,  353 
facial  paresis  in,  353 
Flexuer's  serum  in,  360 
fontanelle  in,  356 
herpes  in,  356 
hydrotherapy  in,  362 
hypersesthesia  in,  352 
infection  in,  mode  of,  348 
in  influenza,  34ii 
Kernig  symptom  in,  352 
leucocyte  count  in,  354 
lumbar  puncture  in,  357,  360 
Macewen's  sign  in,  353 
measles  and,  304 
mydriasis  in,  354 
neck  rigidity  in,  352 
onset  of,  349,  350,  351 
opisthotonos  in,  352 
paralysis  in,  353 
pathology  of,  349 
prognosis  of,  359 
pulse  in,  354 
reflexes  in,  352 
respiration  in,  354 
sequelae  of.  357 
skin  in,  356 
spleen  in,  356 
sporadic,     cerebrospinal     fluid 

in,  76 
symptoms  of,  849 

cerebral,  351 
tache  cerebrals  in,  352,  359 
temperature  in,  355 
treatment  of,  360 
diagnosis   of,   from   convulsions   in 
infancy,  800 


Meningitis,    diagnosis    of,    from    lobar 
pneumonia,  629 
from  typhoid  fever,  330 
lobar  i^neumonia  and,  627 

lumbar  puncture  in,  77,  78 
in  phlebitis  umbilicalis,  211 
position  of  head  in,  38 
posterior  basic,  364 

complications  of,  365 
etiology  of,  364 
hydrocephalus  in,  365 
occurrence  of,  364 
opisthotonos  in,  365 
rigidity  in,  365,  366 
symptoms  of,  365 
treatment  of,  366 
in  scarlet  fever,  275 
serosa,  366 

cerebrospinal  fluid  in,  368 
diagnosis  of,  368 

from   meningitis,   cerebro- 
spinal, 368 
tuberculous,  368 
from    otitis    media    puru- 
lenta,    368 
etiology  of,  367 
lumbar  puncture  in,  368 
occurrence  of,  366 
pathology  of,  367 
spine  in,  47 
suppurative,  cerebrospinal  fluid  in, 

76 
tuberculous,  432 

Babinski 's    reflex    in,    49,    50, 

435,  439 
bacteriology  of,  441 
blood  in,  440 
cerebral  cry  in,  440 
cerebrospinal  fluid  in,  76 
Cheyne-Stokes    respiration    in, 

434,  439 
Chvostek's  symptom  in,  435 
diagnosis  of,  difi:erential,  442 
from  cerebrospinal  menin- 
gitis, 358 
from     meningitis     serosa, 
368 
etiology  of,  432 
eyes  in,  440 
facial  paralysis  in,  435 
hypera?sthesia  in,  439 
in  hysteria,  805 
Kernig 's  symptom  in,  435,439 
lumbar  puncture  in,  441 
Macewen  's  sign  in,  441 
occurrence  of,  432 
onset  of,  438 
pathology  of,  432 
prognosis  of,  443 
pulse  in,  439 
respiration  in,  439 
rigidity  in,  438 
symptoms  of,  433 
treatment  of,  443 
Trousseau's  symptom  in,  435 
tuberculin  test  in,  442 


INDEX. 


923 


i\[oiii Ileitis,  tubcrculoii.s,  vcjiiiiting  in,  438 
vertical,  363.    Hce  Lejtto-meningitis, 

acute 
vomiting  in,  508 
Meningocele  spinalis,  881,  883 
Meningococcus  meningitis,  347 
]\reningo-encepha]ocele,  880 
Menstruation,  effect  of,  on  human  milk, 

98 
Mental  development,  34,  35,  36 

hysteria,  802 
Mesenteric  glands,  tuberculosis  of,  431 
Metabolism  in  newborn,  177 
Metapneumonic  pleurisy,  657 
Microeephalus,  forms  of,  877 

premature  closure  of  f  ontanelles  in, 
38 
Microdontism  in  syphilis,  473 
Micromelia,  250 
Milia  in  newborn,  171 
Miliaria  alba,  892 

rubra,  892 
Miliary  tuberculosis,  421 
Milk,   animal,   comparison   of,  with  hu- 
man milk,  92 
boiled,  assimilation  of,  109 
breast-.     See  Milk,  human. 
burette.  Woodward's,  102 
condensed,  113 

composition  of,  113 
dilution  of,  113,  114 
in  gastro-enteritis,  113,  114 
rachitis  from,  113 
scurvy  from,  113 
cows',  102 

acidity  of,  106 
albumin  in,  102 
bacteria  in,  104,  105 
Bacterium  lactis  aerogenes  in, 

105,  106 
Bacillus  mesentericus  vulgatus 
in,  105 
subtilis  in,  105 
calories  in,  86 
carbohydrates  in,  85 
casein  in,  91,  102,  103 
composition  of,  102 
diluents  for,  149 
fats  in,  84,  102,  103 
infected,  105 

cholera  asiatica  and,  105 
diphtheria  and,  105 
dysentery  and,  105 
scarlet  fever  and,  105 
tuberculosis  and,   105 
laetalbumin  in,  102 
lactic  acid  in,  102,  103 
lipase  in,  94 
mineral  salts  in,  83 
]>asteurization  of,  106 
phosphorus  in,  103 
potato  bacillus  in,  105 
proteids  in,  103 
reaction  of,  102 
specific  gravity  of,  102 
sterilization  of,   107 


Milk,  cow's,  sugar  in,  102 

water  in,  102 
frozen.  111 

constipation  from.  111 

diarrhoea  from.  111 

fat-globules  in.  111 
human,  90 

agglutinins  in,  97,  98 

alcohol  and,  97 

alexins  in,  17,  88,  89,  94,  95 

amount  of,  daily,  96 

amylase  in,  94 

analysis  of,  99 

antitoxins  in,  97,  98 

bacteria  in,  94 

bacillary  infection  of,  97 

calories  in,  86 

carbohydrates  in,  85 

casein  in,  84,  91,  92,  103 

caseinogen  in,  91 

changes  in,  daily,  96 

chemistry  of,  91,  92,  93 

colostrum  in,  89 

cornj^arison     of,    with    animal 
milk,  92 

composition  of,  91,  92 

consumption  of,  daily,  95 

at  nursings,  individual,  95 

crescent-shaped  bodies  in,  93 

diphtheria  and,  97,  98 

drugs  in,  97 

effect  of  beer  on,  96 
of  coffee  on,  97 
of  foods  on,  96 
of  menstruation  on,  98 
of  pregnancy  on,  99 
of  starvation  on,  96 
of  tea  on,  97 

enzymes  in,  88,  89,  94 

fats  in,  84,  93,  100 

estimation  of,  100,  101 

fatty  acids  in,  93 

ferments  in,  94 

first  appearance   of,  90 

foreign  substances  in,  97 

iodine  in,  97 

iron  in,  93 

Konig's  analysis  of,  91 

laetalbumin  in,  84,  92 

lactoglobulin  in,  92 

lecithin  in,  92,  93 

lipase  in,  94 

mineral  salts  in,  83 

nucleon  in,  93 

opalisin  in,  92 

proteids  in,  92 

estimation  of,  102 

reaction  of,  93,  94 

salicylic  acid  in,  97 

salts  in,  93 

specific  gravity  of,  94,  99,  100 

Staphylococcus  albus  in,  94 

tetanus  and,  98 

toxins  in,  97,  98 

tuberculosis  and,  97,  98 

typhoid  fever  and,  97,  98 


924 


INDEX. 


Milk,  human,  water  in,  82 

whey  proteids  in,   91 
modified,  140 

in   eongenitallv   weak   infants, 

192 
formulae  for,  147 
in  newborn,  171 

pasteurized,  assimilation  of,  109 
peptonized,  112,  154.  155 

in   cougenitally   weak   infants, 

192 
preparation  of,  112 
powder,  peptogenic,  112 
raw,  assimilation  of,  109 
diarrhoea  from,  110 
in  infant  feeding,  110 
from  limited  herd,  110 
sterilized,  assimilation  of,  109 

bone    disturbances    from,    110, 

111 
constipation  from,  108 
scurvy  from,  108 
sugar,  85 

digestion  of,  497,  498 
teeth,  470 

test  for  cleanliness  of,  143 
top,  141 

home-made,  143 
seven  per  cent.,  142 
twelve  per  cent.,  142 
of  wet-nurse,  126 

nail-test  for,  126 
witches',  171 
Mineral  salts,  in  cows'  milk,  83 
in  human  milk,  83 
percentage  of,  83 
required  by  infants,  87 
role  of,  in  nutrition,  83 
Mongolian  idiocy,  facial  expression  in, 
40 
palpebral  fissure  in,  40 
Monorchism,  182 
Morbidity  in  childhood,  17 

in  newborn,  17 
Morbilli,  294.     See  Measles 

hsemorrhagica,  300 
Morbus  maculosus  Werlhofii,  749 
Moro's  inunction  tuberculin  test,  424 
Mortality,  18,  19 

artificial  feeding  and,  18 
Mouth,  angles  of,  ulcerations  of,  475 
diagnosis  of,  475 
etiology  of,  475 
symptoms  of,  475 
bacteria  of,  62,  469 
care  of,  61 
diseases  of,  468 
ferment  of,  468 
gonorrheal  infection  of,  481 
symptoms  of.  482 
treatment  of,  482 
normal,  landmarks  of,  469 
in  scarlet  fever,  271,  276 
ulceration  of.  62 
washing  of,  61,  62 


Mouth-breathing,  adenoid  growths  and, 
581 

facial  expression  in,  39 
Mouth-to-mouth     method     of     artificial 

respiration,  196 
Movements,  habit,  831 
Mucin,  82,  84 
Mucous  membranes  in  newborn,  17 

in  rotheln,  292 
Multiple  neuritis,  854 
Mumps,  368 

age  and,  369 

albuminuria  in,  371 

diagnosis  of,  372 

etiology  of,  368 

incubation  in,  369 

influenza  and,  372 

lymph-nodes  in,  370 

measles  and,  372 

metastasis  of,  371 

otitis  and,  371 

pathology  of,  369 

pneumonia  and,  371 

prognosis  of,  372 

symptoms  of,  370 

treatment  of,  372 

typhoid  fever  and,  372 

urine  in,  371 

varicella  and,  372 
Murmurs,  cardiac,  704 
accidental,  705 

arterial,  706 
anemic,  705 
aortic,  705 
in  chorea,  828 
dynamic,  705 
febrile,  705 
Muscles,  carbohydrates  in,  85 
Muscular  atrophy,  49 

hypertrophy,  49 

paralysis,  pseudohypertrophic,  873 

power  in  newborn,  175 

rheumatism,  467 

sense  in  newborn,  175 
Myocarditis,  706 

adherent  pericardium  and,  681 

arrhythmia  in,  708 

bacteria  and,  706 

bacteriology  of,  707 

bradycardia  in,  708 

chronic    valvular    disease    of   heart 
and,  708 

diagnosis  of,  708 

diphtheria  and,  707 

dyspnffia  in,  708 

etiology  of,  706 

exanthemata  and,  706 

gallop-rhythm  in,  708 

in  influenza,  341 

in  measles,  303 

pathology  of,  706 

in  pericarditis,  675 

pertussis  and,   708 

pneumonia  and,  708 

poisons  and,  706 

pulse  in,  708 


INDEX. 


925 


Myocarditis,   pulse-respiration   ratio   in, 
708 

in  scarlet  fever,  279 

septic  conditions  and,  708 

symptoms  of,  707 

toxic,  707 

toxins  and,  706 

treatment  of,  708 
Mydriasis    in    cerebrospinal    meningitis, 

354 
Myelocystocele,  881,  882 
Myelogenous  leukaemia,  743 
Myelomeningocele,  880,  881,  882 
Myotonia,  815 

N 

Nanism,  726 
Nasal  catarrh,  acute,  574 
chronic,  576 
polypi,  diagnosis  of,  from  adenoid 
growths,  583 
Nasopharynx,  diseases  of,  574 
Neave  'a  food,  121 

Nephritis,  acute,  bacteria  and,  776,  777 
constipation  in,  780 
diffuse,  776,  777 
duration  of,  781 
dysentery  and,  778 
etiology  of,  776 
exudative,  776,  777 
fainting  spells  in,  780 
gastro-enteritis  and,  778 
headache  in,  780 
heart  in,  780 

infectious  diseases  and,  776 
lungs  in,   780 
oedema  in,  780 
parenchymatous,  776,  777 
pathology  of,  777 
primary  forms  of,  781 
productive,  776 
pulse  in,  780 
scarlet  fever  and,  776 
symptoms  of,  778 
temperature  in,  780 
toxins  and,  776,  777 
treatment  of,  782 
urine  in,  778,  779,  780 
vomiting  in,  779 
chronic,  diffuse,  781 

symptoms  of,  781 
treatment  of,  782 
productive,  781 
without   exudation,   781 
diagnosis   of,    from   cyclic   albumi- 
nuria, 772 
diphtheria  and,  389 
enema  in,  73 

in  follicular  amygdalitis,  590 
glomerular,  776 
in  influenza,  341,  343 
in  measles,  304 

oedenia  of,  diagnosis  of,  from  scler- 
ema adiposum,  227 
in  scarlet  fever,  277,  278,  289 


Nephritis,  tubular,  776 

in  varicella,  312 
Nervous    disease,    organic,    contra-indi- 
tion  to  maternal  nursing,  124 
system,  disease  of,  sudden  death  in, 
21 
diseases  of,  797 
in  newborn,  175 
in  rachitis,  245 
in  sepsis  in  newborn,  203 
Nestle 's  food,  120 
Neuritis,  measles  and,  304 
multiple,  854 

chorea  and,  825 
diagnosis   of,   855 

from    acute   poliomyelitis, 
871 
etiology  of,  854 
paralysis  in,  855 
pathology  of,  854 
-sensory  disturbances  in,  855 
symptoms  of,  854 
treatment  of,  856 
wrist-drop  in,  855 
muscular  atrophy  in,  49 
optic,  in  amaurotic  idiocy,  839 

in  tumor  of  brain,  841 
patellar  reflex  in,  49 
Newborn,  acute  infectious  osteomyelitis 
and,  757 
amylolytic  ferments  in,  169 
anomalies  in,  181 
asphyxia  in,  193 
atelectasis  in,  198 
bacteria  and,  17,  18 
barley-gruel  in,  use  of,  157,  158 
bile  in,  169 
blood  in,  168 
body-temperature  in,  170 

fluctuation  in,  170 
breasts  in,  171 
caking  of  breasts  in,  231 
cephalohajmatonia  in,  234 
cerebrum  in,  175 
circulation  in,  167 
cold  sense  in,  177 
color  of,  170 
deafness  in,  176 
desquamation  in,  17,  170 
digestion  in,  of  alouminoids,  169 
of  fats,  169 
of  starch,  169 
digestive  functions  in,  169 
diseases  of,  165 
ductus  Botalli  in,  167 
electrical  stimulation  in,  175 
epidemic  ha?moglobinuria  in,  222 
excretion  in,  177 
eye  reflexes  in,  176 
acute  fatty  degeneration  of,  221 
diagnosis  of,  222 
etiology  of,  221 
hemorrhages  in,  219 
pathology  of,  222 
prognosis  of,  222 


926 


INDEX. 


Xewborn,   acute   fatty  degeneratiou   of, 
in    sepsis    in    new- 
born. 201 
symptoms  of,  222 
treatment  of,  222 
haematoma  of  sternomastoid  muscle 

in.  233 
hearing  in,  176 
heat  sense  in.  177 
hemorrhages  in.  219 
hydrochloric  acid  in,  169 
icterus  in,  217 

gravis  in,  218 
infections  in,  17 
jaundice  in,  171 
lanugo  in,   171 
lip  reflex  in,  176 
lungs  in,  166 

aeration  of,  166 
mastitis  in.  232 
meconium  in,  174 
mela^na  in,  219 
metabolism  of,  177 
milia  in,  171 
morbidity  in,  17 
mortality  of,  179 
motion  in,  175 
mucous  membranes  in.  17 
muscular  power  in,  175 

sense  in,  175 
nervous  system  in,  175 
ophthalmia  of,  228 
pain  sense  in,  176 
pancreatic  secretion  in.  169 
paralysis  in,  232 
patellar  reflex  in,  175 
pemphigus  of,  894 
pepsin  in,  169 
peritonitis  of,  213 
perspiration  of,  171 
physiology  of,  165 
pulse  in,  168 

arrhythmia  of,  168 
rectal  excreta  in,  174 
respiration  in,  165 
saliva  in,  169 
sclerema  in,  224 

adiposum  in,  224 
secretion  of  parotid  gland  in,  169 

of  submaxillary  gland  in,  169 
sepsis  in,  201 

auto-infection  in,  202 

bacteria  in,  201 

Bednar's  aphtha-  in,  203 

blood-cultures  in,  204 

bones  in,  203 

bronchitis  in,  201 

Buhl's  disease  in,  201 

dermatitis  exfoliativa  and,  201 

diagnosis  of,  204 

diarrhopa  in,  201.  205 

digestive  tract  in.  2(i2.  204 

ears  and,  202 

Epstein's  pearls  in,  203 

etiology  of,  201 

eyes  and,  202 

hemorrhage  in.  204,  219 


Newborn,  sepsis  in,  hemorrhagic   condi- 
tions in,  201 

hetero-infection  in,  201 

joints  in,  203 

liver  in,  204 

lumbar  puncture  in,  205 

mouth  in,  203 

nervous  system  in,  203 

pathology  of,  204 

pericarditis  in,  204 

pneumonia  in,  201,  206 

prognosis  of,  205 

pseudomembranous  deposits  in, 
203,  205 

respiratory   tract   in,   202.   204 

skin  in,  202 

splenic  puncture  in,  205 

symptoms  of,  202 

temperature  in,  204 

treatment  of,  205 

umbilicus  and,  202,  203 

urine  in,  204 

urogenital  tract  and,  202 

vagina  in,  203 

weight  in,  204 

Wiuckel's  disease  in,  201 
septic  infection  of,  201 
skin  in,  170 

reflex  in,  175 
smell  in,  176 
sudden  death  in,  179 
syphilitic,  hemorrhages  in,  219 
taste  in,  176 
temperature  in,  170 
tetanus  of,  214 
touch  sense  in,  176 
umbilical  arteries  in,  167 

veins  in,  168 
urea  in,  173 
uric  acid  in,  173 
urine  in,  172 

albumin  in,  174 

in  bottle-fed,  172 

in  breast-fed,  172 

casts  in,  173 

color  of,  173 

reaction  of,  173 

specific  gravity  of,   173 

urea  in,  173 

uric  acid  in,  173 
vagus  nerve  in,  175 
vernix  caseosa,  170 
waste  in,  177 

weight  of,  decrease  in,  179 
Winekel's  disease  in,  222 
"witches'  milk"  in,  171 
Night-terrors,  821 
Aipples  of  bottles,  care  of,  62 
of  breast,  care  of,  61 
care  of,  after  nursing,  129 
fissured,  128 

prevention  of,  128 

shield  for,  Davidson  's,  128 

treatment  of,  129 
Nitroglycerine,  dosage  of,  64 
Noma,  483 


INDEX. 


927 


Noma,  bacillus  of  Babes  in,  483 
of  cliphtheria  in,  483 

etiology  of,  483 

in  measles,  305 

prognosis  of,  484 

symptoms  of,  483 

treatment  of,  484 
Non-convulsive  hysteria,  803 
Normal  children,  variations  in,   22,  23 
Nose,  congenital  syphilis  of,  574 

diseases  of,  574 

examination  of,  574 

foreign  bodies  in,  578 

symptoms  of,  578 
treatment  of,  579 

septum  of,  deformity  of,  574 

syringing  of,  66 
Nucleon  in  human  milk,  93 
Nursery,  59 

temperature  of,  59,  60 
Nursing,  beginning  of,  after  birth,  127 

bottle.  111 

frequency  of,  127 

infant,  metabolism  in,  85 

lip  reflex  in,  468 

maternal,  122 

physiology  of,  468 

tube,  188 

Breck's,  189,  190 
Nutation,  nystagmus  in,  40 
Nutrition,  81 

disturbances    of,    diseases    due    to, 
237 

principles  underlying,  81 
Nutroa  food,  121 
Nystagmus,  40,  832 

in  albinism,  40 

in  amaurotic  idiocy,  40 

in  congenital  cataract,  40 

in  corneal  cataract,  40 

in  hereditary  ataxia.  858 

in  infantile  amblyopia,  40 

in  nutation,  40 

in  rachitis,  40 

rhythmic  movements  of  head  and, 
832 

in  spasms,  40 

O 

Oatmeal,  composition  of,  115 
gruel,  114 

preparation   of,   114 
Obstetrical  palsy,  855 
Occipital  lobe,  tumors  of,  841 
O'Dwyer's  tubes  in  diphtheria,  402 
CEdema  in  acute  nephritis,  780 
glottidis,  594 
of  glottis,  594 

etiology  of,  595 

infectious  diseases  and,  595 

pathology  of,  595 

prognosis  of.  595 

symptoms  of,  595 

trauma  and,  595 

treatment  of,  595 


Oedema     of     glottis,     without     kidney 
lesion,   773 
of    nephritis,    diagnosis    of,    from 
sclerema  adiposum,  227 
Ctlsophagitis,  490 
caustic,  490 

etiology  of,  490 
symptoms  of,  490 
treatment  of,  491 
GEsophagus,  branchial  cysts  of,  488 
fistulEe  of,  488 
congenital  anomalies  of,  488 
stricture  of,  489 
absence  of,  490 
atresia  of,  490 
diseases  of,  488 
diverticula  of,  488 
hysterical  stricture  of,  803 
traumatic  stricture  of,  490 
Olein,  84 
Omphalorrhagia,  211 

in  faulty  ligation  of  cord,  211 
true,  212 

in  congenital  syphilis,  212 
etiology  of,  212 
in  fatty  degeneration,   212 
in  septic  infections,  212 
symptoms  of,  212 
treatment  of,  213 
Omphalitis,  206 
Onychia  in  typhoid  fever,  327 
Opalisin  in  human  milk,  92 
Ophthalmia,  diphtheria  and,  392 
gonorrhoea!,  55,  56,  228 
neonatorum,  228 

blindness  and,  228 
complications  of,  229 
Crede  method  in,  230 
diagnosis  of,  229 
etiology  of,  228 
prognosis  of,  230 
prophylaxis  of,  230 
symptoms  of,  229 
treatment  of,  230 
Opisthotonos    in    cerebrospinal    menin- 
gitis, 352 
in  lobar  pneumonia,  623 
Opmus  food,  121 
Orthopncea  in  pericarditis,  676 
Orthostatic  albuminuria,  770 
Osteochondritis   in   hereditary    syphilis, 

454 
Osteogenesis  imperfecta,  252 
diagnosis  of,  253 

from       chondrodystrophia 

fcBtalis.  253 
from  rachitis,  253 
from  syphilis,  253 
etiology  of,  253 
pathology  of,  252 
symptoms  of.  252 
traumatism  and,   253 
treatment  of,  254 
Osteomyelitis,  acute  infectious.  756 
bacteriology  of,  756 
bones  in,  changes  of,  757 


928 


INDEX. 


Osteomyelitis,     acute    infectious,     diag- 
nosis of,  758 
from  congenital  syph- 
ilis, 758 
from  scorbutus,  758 
from    tuberculous   in- 
flammation, 758 
etiology  of,  756 
measles  and,  757 
in  newborn,  757 
pathology  of,  757 
pneumonia  and,  757 
prognosis  of,  758 
scarlet  fever  and,  757 
symptoms  of,  757 
treatment  of,  758 
bronchopneumonia  and,  692 
endocarditis  and,  690 
Otitis,  bacteriology  of,  759 
bones  in,  change  in,  760 
bronchopneumonia    and,    640,    759, 

761 
cerebral  abscess  and,  760 
diagnosis  of,  764 
etiology  of,  759 
examination  of  ear  in,  762 
exanthemata  and,  759 
exfoliated  epithelium  in,  764 
exudates  in,  760 
facial  palsy  and,  851 
in  follicular  amygdalitis,  590 
lobar  pneumonia  and,  626 
in  measles,  305 

media  catarrhalis,  759,  760  *" 

in  influenza,  344 
purulenta,  759,  760 

diagnosis  of,  from  menin- 
gitis serosa,  368 
mumps  and,  371 
pathology  of,  759 
perforation  of  drum  in,  761 
pneumonia  and,  761 
prognosis  of,  764 
in  scarlet  fever,  273,  290 
in  scrofulosis,  414 
symi^toms  of,  760 
tympanic  membrane  in,  759 
tympanum  in,  appearance  of,  764 
in  typhoid  fever,  326 
in  varicella,  313 
Otogenic  infections,  202 
Ovaries,  metastasis  of  mumps  to,  371 
Over-feeding   in    mixed    infant-feeding, 

132 
Oxyuris  vermicularis,  557 

treatment  for,  557 
Oza?na  in  scrofulosis,  413 


Pack,  cold,  65 

Pachymeningitis,    external    hydrocepha- 
lus* and,  836 
Pain  sense  in  newborn,  176 
Palmitin,  84 
Palpation  of  chest,  43 


Palpebral  fissure,  40 
Palsy,  birth,  232.  843 

cerebral,  birth,   diagnosis  of.  from 
Erb's  palsy,  857 
diagnosis  of,  from  acute  polio- 
myelitis, 871 
patellar  reflex  in,  49 
infantile,  843 
acute,  850 
aphasia  in,  848 
athetosis  in,  848 
contractures  in,  846 
convulsions  in,  845 
diagnosis  of,  850 

from   infantile   paral- 
ysis,  850 
diplegia  in,  844 
epilepsy  in,  845,  849 
etiology  of,  843,  845 
gait  in,  846 
hemiplegia   in,   846 
hemiplegic,  845 
infectious     diseases     and, 

845 
mental  state  in,  845 
ocular  palsies  in,  847 
paralysis  in,  844,  845,  846 
pathology  of,  849 
porencephaly  in,  849 
position  in,  846 
post-hemiplegic  chorea  in, 

848 
prognosis  of,  849,  850 
reflexes  in,  846 
sensibility  in.  847 
symptoms  of,  844,  845 
treatment  of,  851 
trophic     disturbances     in, 
848 
Erb's,  857 

diagnosis  of,  857 

from    cerebral    birth    pal- 
sies, 857 
prognosis  of,  857 
symptoms  of,  857 
treatment  of,  857 
facial,  851 

basilar   disease   of   brain   and, 

853 
caries  of  bone  and,  852 
mastoid  disease  and,  851,  852- 
operative,  853 
otitis  and,  851 
symptoms  of,  853,  854 
treatment  of,  854 
infantile,  epilepsy  and.  820 
nuclear,  facial  expression  in,  39 
obstetrical.  857.     See  Palsy,  Erb's 
ocular,  in  infantile  cerebral  palsy, 
847 
Paludism,  334.     See  also  Malarial  fever 
Pancreas,  ferments  of,  498 

secretions  of,  497 
Pancreatic  secretion  in  newborn,  169 
Panophthalmitis  in  scarlet  fever,  276 
Paradysentery,  528.     See  also  Dysentery 


INDEX. 


929 


Paralysis,  acute  atrophic,  861 

in  acute  encephalitis,  860,  861 

poliomyelitis,  868,  869 
in  amaurotic  idiocy,  838,  839 
Bell's,  851 
birth,  232 

position  of  head  in,  38 
symptoms  of,  232 
treatment  of,  232 
in  cerebrospinal  meningitis,  353 
diagnosis  of,  from  rachitis,  246 
diphtheritic,  391 

ataxic  gait  in,  50 
cardiac,  390 
patellar  reflex  in,  49 
position  of  head  in,  38 
essential  of  children,  861 
facial,    in    tuberculous    meningitis, 

435 
in  hysteria,  804 
infantile,  861 

diagnosis    of,    from    infantile 

cerebral  palsy,  850 
limping  gait  in,  51 
in  infantile  cerebral  palsy,  844 
Landry's,  patellar  reflex  in,  49 
in  multiple  neuritis,  855 
ocular,  in  acute  encephalitis,  861 
post-diphtheritic,  391 
pseudohypertrophic   muscular,    873, 
875 
complications  of,  875 
consanguinity  and,  873 
diagnosis  of,  875 

from  congenital  spas- 
tic paralysis,  875 
electrical  reaction  in,  875 
etiology  of,  873 
gait  in,  50,  874 
pathology  of,  875 
prognosis  of,  875 
reflexes  in,  875 
sensation  in,  875 
symptoms  of,  874 
treatment  of,  875 
varieties  of,  875 
of  soft  palate  in,  395 
traumatic,  diagnosis  of,  from  teta- 
nus of  newborn,  216 
Paralytic  form  of  idiocy,  878 
Paranephritis,  788 
Paraplegia,  843 

congenital     spastic,     diagnosis     of, 
from  pseudohypertrophic  muscu- 
lar paralysis,  875 
hereditary  ataxic,  858 
spastic,  spastic  gait  in,  51 
Parasites,  intestinal,  555 

of  liver,  567 
Paratyphlitis,  547 
Parathyroid  gland  in  tetany,  809 
Parenchymatous  nephritis,  acute,  776 
Paresis,  facial,  in  cerebrospinal  menin- 
gitis, 353 
Parietal  lobe,  tumors  of,  841 
59 


Parotid    gland,    secretion    of,    in    new- 
born, 169 
Parotitis,   enlargement   of   lymph-nodes 
in,  715 
epidemic,  368.     See  also  Mumps 
facial  expression  in,  39 
•    infectious,  diagnosis  of,  from  acute 
adenitis,  716 
in  typhoid  fever,  326 
Pasteurization,     comparison     of,     with 
sterilization,  107,  108 
of  cows'  milk,  106 
disadvantages  of,  108 
effect  of,  on  milk,  106 
in  summer,  109 
in  winter,  109,  110 
Pasteurizer,  Freeman's,  106,  107 
Patellar  reflex,  49 

in  newborn,  175 
Pavor  nocturnus,  821 

adenoids  and,  822 
in  chorea,  825 
epilepsy  and,  822 
etiology  of,  821 
hallucinations  in,  822 
prognosis  and,  822 
treatment  of,  822 
Peliosis  rheumatica,  466,  750 
Pemphigus  neonatorum,  894 
etiology  of,  895 
prognosis  of,  895 
symptoms  of,  894 
treatment  of,  895 
Pepsin  in  newborn,  169 
Peptogenic  milk  powder,  112 
Peptone  pi-eparations,  116 
Peptonized  milk,  112,  116,  154,  155 
Percentage  method  of  artificial  infant- 
feeding,  135,  136 
Percussion  of  chest,  43 

dulness  in,  normal,  612 
Perforating  empyema,  664 
Perforative  acute   appendicitis,   548 

peritonitis,  569 
Perforation  of  drum  in  otitis,  761 
Pericarditis,  674 

abdominal  pain  in,  45 
apex-beat  in,  676 
auscultation  in,  678 
bacteriology  and,  674 
bronchopneumonia  and,  642 
in  chorea,  826 

in  congenitally  weak  infants,  184 
diagnosis  of,  679 

from  pleural  effusions,  679 
dyspnoea  in,  676 
effusion  in,  676,  677 
endocarditis  and,  692 
etiology  of,  674 
exanthemata  and,  674 
facies  in,  676 
forms  of,  674 

fibrinous,  674 
purulent,  674 
tuberculous,  675 
friction-sound  in,  678 


930 


INDEX. 


Pericarditis,  inspection  in,  676 
lobar  pneumonia  and,  628 
in  measles,  303 
myocarditis  in,  675 
occurrence  of,  674 
orthopncea  in,  676 
palpation  in,  676 
pathology  of,  675 
percussion  in,  677 
physical  signs  of,  676 
pleuropericardial  friction-sounds  in, 

679 
pleuropneumonia  and,  674 
prognosis  of,  680 
puncture  of  pericardium  in,  680 
rheumatism  and,  674 
in  scarlet  fever,  276,  279 
in  sepsis  in  newborn,  204 
symptoms  of,  675 
treatment  of,  680 
tuberculosis  and,  674 
Pericardium,  adherent,  681 
etiology  of,  681 
myocarditis  and,  681 
symptoms  of,  681 
diseases  of,  674 

puncture  of,  in  pericarditis,  680 
tuberculosis  of,  432 
Perifolliculitis  abscedens,  891 
Perinephritis,  788 
etiology  of,  788 
pyelonephritis  and,  788 
scarlet  fever  and,  788 
symptoms  of,  788 
treatment  of,  788 
Periodic  vomiting,  503 
Peri-oesophageal  abscess,  491 
Periostitis,  hemorrhagic,  254 
Peristalsis  in  pyloric  spasm,  514 
Peritoneal  cavity,  cysts  of,  diagnosis  of, 
from  acitis,  568 
tumors  of,   diagnosis  of,  from 
ascitis,  568 
Peritoneum,  diseases  of,  567 

tuberculosis  of,  426 
Peritonism,  571 
Peritonitis,  acute,  568 

acquired  constipation  and,  536 
bacteriology  of,  568,  569 
bacterium    coli    communis    in, 

569 
blood  in,  570 
constipation  in,  569 
diagnosis  of,  570 

from  typhoid  fever,  570 
etiology  of,  568 
onset  of,  569 
pain  in,  569 
prognosis  of,  570 
symptoms  of,  569 
vomiting  in,  569 
gonococcal,  570 

diagnosis  of,  571 

from  ap7)endicitis,  571 
etiology  of,  571 
prognosis  of,  571 


Peritonitis,    gonococcal,    sj^mptoms    of, 
571 

treatment  of,  571 
ascaris  lumbrieoides  and,  569 
chronic  simple,  573 
colic  in,  509 
in  dysentery,  532 
of  newborn,  214 
iion-tuberculous,  diagnosis  of,  from 

tuberculosis  of  peritoneum,  429 
perforative,  569 
in  phlebitis  umbilicalis,  211 
pneumococcal,  572 

diagnosis  of,  572 

from  appendicitis,  572 
from  tuberculosis  of  peri- 
toneum, 572 

etiology  of,  572 

primary,  572 

prognosis  of,  572 

secondary,  572 

symjitoms  of,  572 

■umbilicus  in,  572 
pneumococci  in,  569 
septic,  retracted  abdomen  in,  44 
simple  chronic,  573 
tuberculous,  426 

acute,  569 

diagnosis   of,    from    acute   ap- 
pendicitis, 550 

rectal  exploration  in,  46 
tympanites  in,  44 
vulvovaginitis  and,  791 
Perityphlitis,  547 
Perleche,  475 
Permanent  teeth,  471 
Pernicious  anaemia,  752 
Persistent  bronchopneumonia,  648 

tetany,  812 
Pertussis,  bronchopneumonia  and,  638 
convulsiva,  372 

bacteriology  of,  373 

blood  in,  375 

bronchitis  and,  375 

bronchopneumonia  and,  375 

cardiac  dilatation  in,  375 

catarrhal  stage  of,  374 

convulsions  in,  376 

diagnosis  of,  376 

diphtheria  and,  393 

etiology  of,  373 

gastro-enteritis  in,  376 

hemorrhages  in,  376 

incubation  of,  373 

kidneys  in,  375 

jnelancholia  and,  376 

pathology  of,  373 

])neumonia  and,  375 

prognosis  of,  377 

prophylaxis  of,  377 

psychoses  in,  376 

spasmodic  stage  of,  374 

symptoms  of,  374 

treatment  of,  377 

tuberculosis  and,  376 
in  measles,  305 
myocarditis  and,  708 


INDEX. 


931 


Petechial  fever,  347 

Petit  mal,  820 

Phantom  tumor  of  liver,  562 

Pharyngeal  tonsil,  hypertrophied,   580 

Phlebitis  umbilicalis,  210 

abscesses,  metastatic  in,  211 
jaundice  in,  211 
meningitis  in,  211 
peritonitis  in,  211 
pleuritis  in,  211 
pya?niia  in,  211 
treatment  of,  211 
Phlegmon   of  scalp,   diagnosis  of,  from 
cephalohsematoma,  235 
of  umbilicus,  208 
Phlegmonous  laryngitis,  594 
Phosphorus  in  cows'  milk,  103 
Photophobia,  40 

in  measles,  296^  304 
Physical  development,  34,  35,  36 
Pica,  805 

treatment  of,  806 
Pin-worm,  557 
Plasmodium  malaria,  334 
Plastic  bronchitis,  600 
Pleasure,   feelings   of,   development   of, 

35 
Pleura,  diseases  of,  650 
tuberculosis  of,  432 
Pleural   fold,    displacement    of,    in   em- 
pyema, 661 
Pleurisy,  650 

abdominal  pain  in,  45 
bronchiectasis  and,  607,  609 
bronchophony  in,  662 
dry,  650 

diagnosis   of,   651 
etiology  of,  651 
pain  in,  651 
prognosis   of,   651 
symptoms  of,  651 
treatment  of,  652 
hemorrhagic,  672 
lobar  pneumonia  and,  627 
metapneumonic,  657 
purulent,  652 

subacute,  652.     See  also  Empyema 
suppurative,  652 
with  effusion,  650,  652 
Pleuritis,  650 

diphtheria  and,  388 
in  phlebitis  umbilicalis,  211 
in  scarlet  fever,  280 
Pleuropericardial  friction-sounds  in  per- 
icarditis, 679 
Pleuropneumonia,  pericarditis  and,  674 
Pneumococcal  peritonitis,  572 
Pneumococci  in  peritonitis,  569 
Pneumococcus    of    Frankel    in    broncho- 
pneumonia, 633 
Pneumonia,  abdominal  pain  in,  45 
acetone  in  urine  in,  33 
acute  infectious  osteomyelitis  and, 

757 
bronchiectasis  and,  607,  609 
catarrhal,  632 


Pneumonia,  colic  in,  509 
croupous,  615 
cystitis  and,  793 

diagnosis    of,    from    cerebrospinal 
meningitis,  359 

from  typhoid  fever,  330 
endocarditis  and,  690 
fibrinous,  615 

bronchitis  and,  600 
full  bath  in,  65 
gavage  in,  71 
hemorrhagic,  in  congenitally  weak 

infants,  184 
in  influenza,  342 
Kernig's  symptom  in,  50 
lobar,  615 

age  and,  615 

bacteriology  of,  617 

blood  in,  623 

bradycardia  in,  621 

chills  in,  622 

complications  of,  626 

cough  in,  618,  622 

crisis  in,  618 

delirium  in,  622 

diagnosis  of,  629 

from    acute    appendicitis, 

551 
from      bronchopneumonia, 

645 
from  influenza,  629 
from  meningitis,  629 
from  typhoid  fever,  629 

dyspnoea  in,  618,  622 

empyema  and,  627,  628,  652 

etiology  of,  617 

gray  hepatization  in,  616 

hydrotherapy  in,  630 

hygiene  in,  632 

induration  of  lung  in,  617 

in  influenza,  341 

leucocytosis  in,  623 

melancholia  in,  623 

meningitis  and,  627 

occurrence  of,  615 

onset  of,  618 

opisthotonos  in,  623 

otitis  and,  626 

pain  in,  618 

pathology  of,  616 

pericarditis  and,   628 

physical  signs  of,  623 

pleurisy  and,  627 

prognosis  of,  628 

rale,  crepitant  in,  624 
rednx  in,  625 

sex  and,  615 

of  short  duration,  625 

situation  of,  615 

stages  of,  624,  625 

symptoms  of,  617 

temperature  in,  619,  620,  621 

treatment  of,   630 

tympanites  in,  631 
lobular,  632 
lumbar  puncture  in,  78 


932 


INDEX. 


Pneumonia  in  measles,  301,  302 
mumps  and,  371 
otitis  and,  761 
myocarditis  and,  708 
pertussis  convulsiva  and,  375 
in  scarlet  fever,  280 
in  scleroedema,  225 
in  sepsis  in  newborn,  201,  206 
tympanites  in,  45 
in  typhoid  fever,  326,  328 
in  varicella,  313 
Pneumonic  fever,  615 
Poisoning,  stomach  washing  in,  70 
Polioencephalitis,  acute,  859 
Poliomyelitis,  acute,  861 
atrophy  in,  870 
bone  in,  retardation  of  growth 

of,  870 
brain  in,  863 
diagnosis   of,   871 

from  cerebral  palsy,  871 
from  cerebrospinal  menin- 
gitis, 871 
from  multiple  neuritis,  871 
forms  of,  864,  865 
abortive,  867 
ataxic,  867 
bulbar,  865 
cerebral,   867 
encephalitic,  867 
polyneuritic,  867 
pontine,  865 

simulating    Landry's    pa- 
ralysis, 865 
paralysis  in,  868,  869 
pathology  of,  862 
prognosis  of,  871 
sequete  of,  872 
symptoms  of,  864 
treatment  of,  872 
anterior.     See   Poliomyelitis,   acute 
epidemic.     See  Poliomyelitis,  acute 
muscular  atrophy  in,  49 
patellar  reflex  in,  49 
Polyarthritis  rheumatica,  459 
Polycythaemia,  734 
Polydipsia  in  diabetes  mellitus,  712 
Polypoid  tumors  of  umbilicus,  207 
Polypus  of  rectum,  554 
Polyuria,  712 
Pons,  tumors  of,  842 
Porencephaly  in  infantile  cerebral  palsy, 

849 
Post-diphtheritic  paralysis,  391 
Post-hcmiplegic  chorea  in  infantile  cer- 
ebral palsy,  848 
convulsions,  diagnosis  of,  from  epi- 
lepsy, 821 
Postural  albuminuria,  770 
Potain's  aspirator  for  empyema,  667 
Pott 's  disease,  position  of  head  in,  38 

spine  in,  47 
Pregnancy,  effect  of,  on  human  milk,  99 
Premature  birth,  19 
infants,  183 

temperature  in,  30 


Proctitis,  554 

gonorrhoeal,  554 
treatment  of,  554 
Productive  nephritis,  acute,  776 

chronic,  781 
Progressive  anaemia  in  uncinariasis 

muscular   atrophy,   Erb's   type   of, 
872 
Prolapsus  ani,  552  v 

etiology  of,  552 
symptoms  of,  553 
treatment  of,  553 
Proteids,    in    artificial    infant-feeding, 
137 
in  artificial  infant  foods,  121 
calories  in,  87 
in  cows'  milk,  103 
estimation  of,  in  human  milk,  102 
estimation  of.  Woodward's  method 

of,  102 
in  human  milk,  92 
low  percentage  of,  154 
ratio  of,  in  food,  86 
role  of,  in  nutrition,  83,  84 
variation  of,  in  cows'  milk,  148 
Pruritus  in  diabetes  mellitus,  712 
Pseudochorea,  82^ 
Pseudocroup,  593 
Pseudodiphtheria,  410 

in  scarlet  fever,  270 
Pseudodiphtheritic  stomatitis,  482 
Pseudohypertrophic  muscular  paralysis, 

873 
Pseudoleuksemia,  747 
Pseudoleukgemic  ansemia,  739 
Pseudo-masturbation,  807 
Pseudomembranous  deposits  in  sepsis  in 
newborn,  203,  205 
rhinitis,  578 
Psoas  spasm,  48 
Psychic  hysteria,  802 
Ptosis  in  typhoid  fever,  328 
Puerile  breathing,  613 

tetany,  813 
Pulmonary  artery  in  congenital  disease 
of  heart,  686 
stenosis  of,  687 
blood  in,  688 
clubbed  fingers  in,  688 
cyanosis  in,  688 
murmur  in,  688 
physical  signs  of,  688 
ventricular       hypertrophy 
of,  688 
dyspnoea,  614 
resonance,  normal,  611 . 
tuberculosis,  421 
Pulse,  arrhythmia  of,  30 
dicrotism  of,  30 
irregularity  of,  30 
in  newborn,  168 
rapidity  of,  29 
rhythm  of,  30 
Pulse-respiration  ratio  in  infants,  29 
Puncture,    lumbar.      Sec    also    Lumbar 
puncture 


INDEX. 


933 


Piiro,  115 

Purpura  hsemorrhagica,  749 

diagnosis  of  various  forms  of, 

750,  751,  752 
etiology  of,  750 
hemorrhages  in,  749 
prognosis  of,   750 
symptoms  of,  749 
treatment  of,  750 
Henoch's,  751 
rheumatica,  750 

etiology  of,  750 
prognosis  of,  751 
symptoms  of,  751  , 

treatment  of,  751 
simple,  748 

etiology  of,  748 
petechise  in,  748 
prognosis  of,  748 
symptoms  of,  748 
treatment  of,  748 
Purulent  otitis  media,  759,  760 
pericarditis,  674 
pleurisy,  652 
Pustular  eczema,  885 
Putrid  bronchitis,  606 
Pyaemia  in  phlebitis  umbilicalis,  211 
Pyelitis,  793.     See  also  Cystitis 
Pyloric  spasm,  congenital,  511 
enemata  in,  517 
gavage  in,  517 
treatment  of,  operative,  517 
stenosis,  511 

congenital  hypertrophic,  511 
constipation  in,  513 
diagnosis  of,  515 
etiology  of,  512 
feeding  in,  516 
pathology  of,  512 
peristalsis  in,  514 
prognosis  of,  516 
symptoms  of,  513 
treatment  of,  516 
vomiting  in,  507,  513 
Pylorus    and    stomach-wall,    congenital 

hypertrophy  of,  512 
Pyelonephritis,  793.     See  also  Cystitis 

perinephritis  and,  788 
Pyopneumothorax,  664 
subphrenicus,  672 
symptoms  of,  664 
Pyuria  in  typhoid  fever,  328 

Q 

Quantitative  estimation  of  fats,  Soxh- 

let's,  101 
Quevenne  's  lactodensimeter,  100 
Quincke  funnel,  80 
needle,  77 

B 

Eachischisis,  879 

cystica,  880 
Rachitis,  237 

acute,  254.     See  Scorbutus,  infantile 


Rachitis,   acute,   simple   bronchitis   and, 
597 
anaemia  in,  245 
blood  in,  245,  246,  735 
' '  bow-leg ' '  deformity  in,  244 
brain  in,  240 

from  condensed  milk,  113 
congenital,  237 
craniotabes  in,  237,  240,  245 
definition  of,  237 

delay  of  closure  of  fontanelles  in,  27 
dentition  in,  471 
diagnosis  of,  246 

from    congenital    internal    hy- 
drocephalus, 834 

from  cretinism,  246 

from  Mongolian  idiocy,  246 

from    osteogenesis   imperfecta, 
253 

from  paralysis,  246 

from  syphilis,  246 
duration  of,  245 
emphysema  of  lungs  and,  602 
enlargement  of  lymph-nodes  in,  716 
facial  expression  in,  39 
fostal,  237 
fontanelles  in,  240 
head  in,  240 
hemorrhagic,  237,  254 
hydrocephalus  in,  240,  245 
hydrochloric  acid  and,  238 
infantile  scorbutus  and,  255 
intestinal  disturbances  in,  244 
intra-uterine,  237 
lactic  acid  and,  238 
laryngismus  stridulus  and,  817 
leukaemia  and,  743 
lime  salts  and,  238 
liver  in,  239,  245 
lymph-nodes  in,  239 
nervous  system  in,  245 
nystagmus  in,  40 
osteoid  tissue  in,  238,  239 
pain  in,  242 
pathology  of,  238 
pelvis  in,  deformity  of,  243 
prognosis  of,  247 
pseudoleuk^mic  angemia  and,  741 
race  and,  237 
respiration  in,  241 
rhythmic   movements   of   head   and 

nystagmus  and,  832 
"sabre"  defoi-mity  in,  244 
severity  of,  245 
sex  and,  237 
shape  of  head  and,  38 
simple,  enlargement  of  liver  in,  562 
spinal  curvatures  in,  243 
spine  in,  47 

deformity  of,  243 
spleen  in,  239,  245 
status  lymphaticus  and,  729 
syphilis  and,  238 
tarda,  246 
theories  of,  238 
thorax  in,  deformity  of,  240 


934 


INDEX. 


Eachitis,  treatment  of,  247 

tympanites  in,  45 
Eale.  crepitant  in  lobar  pneumonia,  624 

redux  in  lobar  pneumonia,  625 
Easli  in  scarlet  fever,  272 

wandering-  of  tongue,  486 
Eaw  milk,  109 
Eectal  enema,  72 

excreta  in  newborn,  174 
feeding,  contra-indicatious  for,  164 
temperature  in  newborn,  170 
table  of,  31 
Eectum,  adenomata  of,  554 
anatomy  of,  552 
exploration  of,  46 
in  abscess,  46 
in  intussusception,  46 
in  tuberculous  peritonitis,  46 
irrigation  of,  72 
polypus  of,  554 
age  and,  554 
diagnosis  of,  555 
location  of,  554 
prognosis  of,  555 
symptoms  of,  555 
treatment  of,  555 
position  of,  552 
Eed  blood-cells,  734 
Eeflex,  Babinski's,  49 

in  tuberculous  meningitis,  49 
patellar,  49 
Eenal  calculi,  775 

etiology  of,  776 
symptoms  of,  776 
treatment  of,  776 
Eesiliency  of  chest-wall,  611 
Eesonance,  pulmonary,  normal,  611 

tympanitic,  normal,  613 
Eespiration,  artificial,   195 

in    asphyxia    in    the    newborn, 

195,  196 
methods  of,  195,  196 
Dew,  196 

mouth-to-mouth,  196 
Schultze,  195,  196 
character  of,  28 
ciiemism  of,  28 
diaphragmatic,  28 
excretion  of  carbon  dioxide  in,  28 
in  newborn,  165 
normal  frequency  of,  28 
Eespiratory   diseases,   sudden    death   in, 
20 
disorders,  facial  expression  in,  39 
disturbances  in  childhood,  17,  18 
system,  diseases  of,  574 
Eetentio  testis,  182 
Eetinitis  in  scarlet  fever,  279 
Eetro-fpsophageal  aliscess,  491 
Eetropharyngcal   al)scess,  585 

lymphadenitis,  5S5 
Ecvacci nation,  318 

Eheumatic  cases   of   follicular  aitiyg(hi- 
litis,  590 
fever,  459 
form  of  faciiil   palsy,  851 


Eheumatic  nodules,   subcutaneous,  466 
Eheumatism,  acute  articular,  459 
age  and.  460 
chorea  in,  462 
endocarditis  and,  690 
endocarditis  in,  461 
etiology  of,  459 
heredity  and,  460 
prognosis  of,  462 
sex  and,  460 
sjaiiptoras  of,  460 
treatment  of,  462 
types  of,  461 
chorea  and,  823,  824 
endocarditis  and,  693 
gonorrhceal,  466 
muscular,  467 
pericarditis  and,  674 
scarlatinal,  277 
Eheumatoid  arthritis,  463 
Ehinitis,  adenoid  growths  and,  580 
diphtheritic,  578 

Klebs-Loffler  bacillus  in,  578 
streptococcic  form  of,  578 
symptoms  of,  578 
treatment  of,  578 
pseudomembranous,  578 
Ehinorrhagia,  579 
Ehythm  of  pulse,  30 
Eiekets,  237 

foetal,  250 
Eidge's  food,  121 
Eigidity  of  spine,  tests  for,  48 
Eingworm  of  tongue,  486 
Eobinson  's  groats,  121 

patent  barley,  114,  121,  158 
Eocking,  evil  effects  of,  59 
Eoger's  disease,   689 
Eoseola,   syphilitic,   diagnosis   of,   from 
measles,  307 
Trousseau's,   291.     See  Eotheln 
in  typhoid  fever,  322 

diagnosis  of,  from  measles,  307 
Eotch's    method    of    artificial    infant- 
feeding,  133,  135 
Eotheln,  291 

complications  of,  293 
desquamation  in,  292 
diagnosis  of,  from  measles,  306 

from  scarlet  te\*er,  282,  293 
eruption  in,  292 
exanthema  in.  291 
genitals  in,  293 
lymph-nodes  in,  292 
nuicous  membranes  in,  292 
jn'odromal  period  of,  291 
prognosis  of,  293 
spleen  in,  293 
symptoms  of,  291 
treatment  of,  293 
Kcnind  worms,  556 

symptoms  of,  556 
treatment   for,   556 
Kuliella,  291.     See  Eotheln 
Iv'nht'ola,  294.     See  Measles 


INDEX. 


935 


S 

"Sabre"   deformity  in  rachitis,  244 
St.  Vitus'  Dance,  822.     See  also  Chorea 
Salicylic  acid  in  human  milk,  97 
Saliva  in  newborn,  169 
Salt  solution,  Cantani's,  66 

in  artificial  infant-feeding,  137 
mineral,  83 

in  human  milk,  93 
Sarcoma  of  kidney,  785 

of  thymus  gland,  729 
Savory  and  Moore's  food,  120 
Scalp,  seborrhcea  of,  886 
Scarlatinal  rheumatism,  277 
Scarlet  fever,  265 

abscess  of  brain  in,  275 
of  skin  in,  272 

acute    infectious    osteomyelitis 
and,   757 
nephritis  and,  776 

albumin  in,  282 

albuminuria  in,  278 

amaurosis  in,  279 

ansemia  and,  280 

angina  in,  267,  270 
membranous,  270 

aphasia  in,  279 

arthritis  and,  277 

bacteriology  of,  284 

blood  in,  280 

bronchopneumonia  and,  639 

cardiac  hypertrophy  in,  280 

chorea  and,  281 

conjunctivitis  in,  276 

contagion  in,  zone  of,  266 

convulsions  in,  279 

cystitis  and,  793 

deafness  in,  275 

descjuamation  in,  273 
duration  of,  274 

diagnosis  of,   281 

from  drug  eruption,  282 
from  measles,  282,  306 
from  rotheln,  282,  293 

diarrhoea  in,  280 

diphtheria  in,  270 

diphtheroid  in,  270 

disinfection  and,  285 

ear  in,  275 

eclampsia  in,  279 

empyema  in,  276 

enanthema  in,  281 

endocarditis  in,  279,  690 

eruption  in,  271 

etiology  of,  265 

exanthema  in,  271 

eye  in,  276 

fever  in,  273 

from  infected  cows'  milk,  105 

full  bath  in,  65 

gangrene  in,  272 
of  lung  in.  280 

glandular  swellings  and,  280 

heart  in,  279 

immunity  to,  267 


Scarlet  fever,  incubation  of,  267,  268 

intestine  in,  280 

joints  in,  277,  290 

kidneys  in,  277 

leucocytosis  in,  280 

lungs  in,  280 

lymph-nodes  in,  270,  273,  276 

mania  in,  279 

mastoid  disease  and,  273,  766 

melancholia  in,  279 

meningitis  in,  275 

mouth  in,  271,  277 

myocarditis  in,  279 

nephritis  in,  277,  278,  289 

nose  in,  274,  287 

otitis  in,  273,  290 

panophthalmitis  in,  276 

pathology  of,  283 

pericarditis  in,  276,  279 

perinephritis  and,  788 

pleura  in,  280 

pleuritis  in,  280 

pneumonia  in,  280 

prognosis  of,  282 

prophylaxis  of,  285 

pseudodiphtheria  in,  270 

psychoses  and,  281 

rash  in,  272 

relapses  in,  281 

retinitis  in,  279 

retropharyngeal      abscess      in, 
271,  276 
adenitis  in,  276 

second  attacks  of,  281 

sequelae  of,  280 

sinus  thrombosis  in,  275 

skin  in,  272,  283 

stomach  in,  280 

stomatitis  in,  277 

strawberry  tongue  in,  271 

streptococcasmia  in,  271 

surgical,  270 

susceptibility  to,  266 

symptomatology  of,  267 

temperature  in,  269 

tongue  in,  271 

tonsillitis  in,  271 

treatment   of,  286 

tuberculosis  and,  280 

uraemia  in,  273,  279 

urine  in,  278 

wound  infection  with,  270 
Schonlein's  disease,  750 
Schultze    method    of    artificial    respira- 
tion, 195,  196 
Sclerema  adiposum,  226 

diagnosis   of,  from   oedema   of 
nephritis,  227 
from  scleroedema,  227 

pathology  of,  227 

prognosis  of,  228 

skin  in,  227 

symptoms  of,  226 

treatment  of,  228 
in  congenitally  weak  infants,  184 
fat-,  226 


936 


IXDEX. 


Sclerema  neonatorum,   224 

in  newborn,  22-i 
Scleroedema,  complications  of,  225 

diagnosis  of,  from  sclerema  adipo- 

sum,  227 
etiology  of,  224 
neonatorum,  224 
pathology  of,  226 
pneumonia  in,  225 
prognosis  of,  226 
symptoms  of,  224 
treatment  of,  226 
Sclerosis,  multiple,  patellar  reflex  in,  49 
Sclerotic  form  of  idiocy,  878 
Scoliosis,   restriction   of   movements   of 

chest  in,  611 
Scorbutus,  infantile,  254 
bones  in,  256" 

fracture  of,  256,  258 
deformities  in,  257 
diagnosis  of,   259 

from  syphilis,  259 
from  acute   infectious   os- 
teomyelitis, 758 
diet  and,  255 
duration  of,  259 
ecchymoses  in,  257 
etiology  of,  254 
gums  in,  257 
hsematuria  in,  256.  257 
hemorrhages  in,  256,  257,  258 

intestinal,  259 
joints  in,  257 
pain  in,  257 
paralysis  in,  257 
pathology  of,  256 
prognosis  of,  259 
pulse  in,  258 
rachitis  and,  255 
symptoms  of,  256 
treatment  of,  259 
urine  in,  251 
Scott's  oat  flour,  121 
Scrofulosis,  411 

bones  in,  412,  415 
cornea  in,  412 
diagnosis  of,  416 
ears  in,  414 
ecthyma  in,  413 
eczema  in,  413 
etiology  of,  411 
eye  in,  414 
joints  in,  412,  415 
lichen  scrofulosorum  in,  413 
lupus  in,  413 
lymph-nodes  in,  412,  414 
mucous  membranes  in,  413 
otitis  in,  414 
ozaena  in,  413 
pathology  of,  412 
prognosis  of,  416 
skin  in,  412,  413 
symptoms  of,  413 
treatment  of,  416 
tubercle  bacillus  and,  412 
Scrotum,  anomalies  of,  congenital,  181 


Scur\"y,  diagnosis  of,  from  intussuscep- 
tion, 545 

infantile,  254 

in  marantic  infants,  159 

rickets,  254 

from  sterilized  milk,  108 
Seborrhcea  eapillitii,  886 

of  scalp,  886 

treatment  of,  890 

of  umbilicus,  886 
Seborrhoeic  eczema,  886 
Sepsis  in  congenitally  weak  infants,  184 

endocarditis  and,  690 

neonatorum,  201 

in  newborn,  201 
icterus  in,  217 
Septic  endocarditis,  696 

infections,  true  omphalorrhagia  in, 
212 
Septum,    auricular,    congenital    defects 
of,  689 

ventricular,   congenital   defects   of, 
689 
Sight,  development  of,  35 

examination  of,  40 
Sinus  thrombosis  in  scarlet  fever,  275 
Sitting,  development  of,  35 
Skin,  care  of,  61,  884 

in  congenitally  weak  infants,  184 

in  diabetes  mellitus,  712 

diphtheria  of,  392 

diseases  of,  884 

eruptions  of,  884 

examination  of,  38,  884 

in  newborn,  170 

desquamation  of,  8S4 

oedema  of,  884 

reflex  in  newborn,  175 

in  scarlet  fever,  272 

in  sepsis  in  newborn,  202 
Skodaic  resonance  in  empyema,  659 
Skull,  deformities  of,  879 
Sleep,  58 

normal  facial  expression  in,  39 

in  open  air,  63 

rapidity  of  pulse  diiriug,  30 

temperature  during,  30 
Smell,  sense  of,  in  newborn,  176 
Solitary  tubercle  of  brain,  443 
Somatose,  116 
Sore    throat,    traumatic,    diagnosis    of, 

from  diphtheria,  396 
Soxhlet    method    of     artificial     infant- 
feeding,  135 
Soxhlet 's     quantitative     estimation     of 

fats,  101 
Spasm  of  anus,  554 

congenital  pyloric,  511 

of  glottis,  816 

habit,  831 

nystagmus  in,  40 

psoas,  48 
Spasmodic  croup,  593 

larj-ngitis,  593 
Spasmophiles.     See   status   Ijmphaticus 

latent  tetany,  730,  812  ' 


INDEX. 


937 


Spasmus  nutans,  832 
Spastic  gait,  51 

hemiplegia,  843,  845 
Speech,  development  of,  36 
Spina  bifida,  880 

deformities  of  foot  in,  882 
diagnosis  of,  882 
occulta,  883 
symptoms  of,  881 
treatment  of,  881 
tumor  in,  881 
Spinal  curvatures  in  rachitis,  293 
canal,  deformities  of,  879 

introduction  of  drugs  into,  80 
of  serum  into,  80 
Spine,  anatomy  of,  47 
deformity  of,  47 
examination  of,  47 
in  meningitis,  48 
painful  areas  in,  47 
in  Pott 's  disease,  47 
in  rachitis,  47 
rigidity  of,  47,  48 
Spitting  in  bottle-fed  infants,  152 
in  breast-fed  infants,  152 
treatment  of,  152 
Splenic  puncture  in  sepsis  in  newborn, 
205 
tumor  in  fibrinous  bronchitis,  601 
Spleen,  anatomy  of,  732 
diseases  of,  732 
enlargement  of,  733 
in  leukaemia,  744 
in  pseudoleuksemic  aneemia,  740 
examination  of,  732,  733 
palpation  of,  733 
percussion  of,  732 
in  rachitis,  239,  245 
in  rbtheln,  293 
size  of,  732 
tumor  of,  734 

diagnosis    of,    from    tumor    of 
kidney,  734 
Sponge  bath,  64,  65 
Sporadic  cretinism,  719 
Spotted    fever,    347.     See    Meningitis, 

cerebrospinal 
Spray,  vapor,  68 
Sprue,  61,  62,  476 
etiology  of,  477 
occurrence  of,  477 
symptoms  of,  477 
treatment  of,  478 
Standing,  development   of,  35 
Staphylococcus  albus  in  human  milk,  94 
Starch,  digestion  of,  in  newborn,  169 
Status  epilepticus,  lumbar  puncture  in, 
77 
lymphaticus,  729 

Chvostek's  symptom  in,  730 
rachitis   and,   729 
symptoms  of,  730 
treatment  of,  731,  732 
Trousseau's     phenomenon     in, 
730 
prsesens,  expression  in,  38 


Status  preesens,  posture  in,  38 

taking  of,  38 
Stearin,  84 
Stenosis  of  aortic  valve,  686 

pulmonary  artery,  687 
Sterilization,  comparison   of,  with  pas- 
teurization, 107,  108 
of  cows '.milk,  107 
disadvantages  of,  107,  108 
effect  of,  on  milk,  107 
in  summer,  110 
Sterilizer,  Arnold's,  107 
Sternomastoid    muscle,    hsematoma    of, 

233 
Stethoscope,   41,  42 

binaural,  42 
Still's  disease,  463,  465 

enlargement  of  liver  in,  563 
etiology  of,  465 
symptoms  of,  465 
Stomach,  acids  of,  495 
anatomy  of,  494 
bacterial  flora  in,  497 
capacity  of,  494 
contents,  examination  of,  37 
digestion  in,  496 
dilatation  of,  509 
etiology  of,  509 
physical  signs  of,  511 
prognosis  of,  511 
symptoms  of,  510 
treatment  of,  511 
vomiting  in,  510 
diseases  of,  493 
function  of,  494 
lab-ferment  in,  496 
milk  sugar  in,  497 
motility  of,  494 
percussion  of,  494 
position  of,  494 
ulcer  of,  511 
washing  of,   69 

indications  for,  69 
in  poisoning,  70 
in  vomiting,  chronic  dyspeptic, 
69 
persistent,  69 
Stomatitis,  61,  62 
aphthous,  478 

bacteriology  of,  479 
etiology  of,  479 
symptoms  of,  479 
treatment  of,  480 
diagnosis  of,  from  diphtheria,  394 
in  measles,  305 
pseudodiphtheritie,  482 
symptoms  of,  482 
treatment  of,  483 
in  scarlet  fever,  277 
toxic,  480 

symptoms  of,  480 
treatment  of,  480 
ulcerative,  480 

etiology  of,  480 
symptoms  of,  481 
treatment  of,  481 


938 


INDEX. 


Stools,  normal,  499 

bacterial  flora  in,  501 
in  bottle-fed  infants.  499 
in  breast-fed  infants,  499 
composition  of,  500 
number  of,  daily,  501 
reaction  of,  500 
variation  of,  in  breast-feeding,  130, 
131 
Streptococcfemia  in  scarlet  fever,  271 
Streptococcic  form  of  diphtheritic  rhi- 
nitis, 578 
Stricture,  congenital,  of  oesophagus,  489 

traumatic,  of  oesophagus,  490 
Stridor,  congenital,  of  infants,  815 
etiology  of,  816 
larynx  in,  816 
respiration  in,  816 
symptoms  of,  815,  816 
laryngeal,  816 
Subacute  pleurisy,  652 
Subcutaneous  tuberculin  test,  425 
Submaxillary    gland,    secretion    of,    in 

newborn,  169 
Subphrenic  abscess,   672 
Sudamina.  61,  892 

Sugar,  in  artificial  infant-feeding,  137 
in  cows'  milk,  102 
grape,  85 
milk,  85 
Summer  diarrhoea,  517 
Sunburn,  60 

Supfjurating    sinus,    persistent,    in    em- 
pyema. 670 
Suppurative  acute  appendicitis,  548 
hepatitis,  566 
pleurisy,   652 
Suprarenal  bodies,  diseases  of,  753 
Sydenham's  chorea,  822 
Svmptomatic  chorea,  822 
Syphilis.  444 

acquired,  444 

diagnosis  of,  444 

from    hereditary    syphilis, 
445 
infection  with,  mode  of,  444 
prognosis  of,  444 
symptoms  of,  444 
acute  simple  bronchitis  and,  597 
of  bones,  756 

of  skull,  756 
bronchiectasis  and,   607 
congenital,  448 

facial  expression  in,  40 
of  nose,  574 

diagnosis  of,  from  acute  infec- 
tious osteomyelitis.   758 
enlargement  of  liver  in,  563 
of  lymph-nodes   in,   715 
true  omphalorrhagia  in,  212 
congeiiitally  weak  infants  and,  184 
contraindication  to  maternal  nur.s- 

ing.  ]2.'{ 
cranial,  diagnosis  of,  from  congen- 
ital internal  hydrocephalus,  836 
dental  amorphism  in,  473 


Syphilis,  dental,  infantilism  in,  473 
dentition  in,  470 

diagnosis  of,  from  osteogenesis  im- 
perfecta, 253 
from  rachitis,  246 
fissure  of  anus  in,  553 
hereditaria  tarda,  445 
hereditary,  448 
bones  in,  451 
CoUes's  law  in.  448 
dactylitis  syphilitica  in,  455 
diagnosis  of,  456 
etiology,  448 

glandular  apparatus  in,  451 
Hochsinger  's      induration      in, 

453 
kidneys  in,  450 
hereditary,  late,  445 

bones  in,  446 
ear  in,  447 
eyes  in,  446 
liver  in,   448 
lymph-nodes  in,  447 
psychoses  in,  448 
skin  in,  447 
spleen  in,  448 
symptoms  of,  445 
liver  in,  450 
lungs  in,  450 
osteochondritis  in,  454 
pancreas  in,  451 
pathology  of,  449 
prognosis  of,  457 
spleen  in,  450 
symptoms  of,  451 
treatment  of,  458 
Hutchinson's  teeth  in,  471 
of  larynx,  596 
leukaemia  and,  743 
of  liver,  565 
microdontism  in,  473 
rachitis  and,  238 
roseola,  diagnosis  of,  from  measles, 

307  » 

of  thymus  gland,  729 
Syphilitic  adenopathy,  715 

form  of  idiocy,  878 
Syringing  of  nose,  66 
Syringomyelocele,  881 


Tabes,    diagnosis    of,    from    hereditary 
ataxia,  859 
mesenterica,  431 
Tache   cerebrale   in   acute    encephalitis, 
860 
in      cerebrospinal     meningitis, 
352,  359 
Tachycardia  in  hysteria,  804 
Ta'nia  elliptica,  557 
mediocanellata,  557 
solium,  557 
Tapeworm,  555,  557 
symptoms  of,  558 
treatment  for,  558 


INDEX. 


939 


Taniier  's  incubator,  186 
Taste,  development  of,  35 

sense  of,  in  newborn,  176 
Tav-Kiugdon 's  sj)ot  in  amaurotic  idiocy, 

839 
Tea,  effect  of,  on  human  milk,  97 
Teeth,  eruption  of,  care  of  mouth  after, 
62       • 
Hutchinson's,  471 
milk,  470 
permanent,  471 
temporary,  470 
Temperature  in  bottle-fed  children,  30 
in  breast-fed  children,  30 
in   congenitally  weak   infants,   185, 

186 
fluctuations  of,  daily,  30 
high,  63 
in  newborn,  170 
in  premature  infants,  30 
rectal  in  newborn,  170 

table  of,  31 
reduction  of,  64 
rise  of,  during  crying,  30 
during  exercise,  30 
during'  excitement,  30 
during  sleep,  30 
taking  of,  56,  57 
axillary,  56 
frequency  of,  57 
positions  for,  56 
rectal,  56,  57 
variations  of,  normal,  30 
Temporary  teeth,  470 
Temporosphenoidal  lobe,  tumors  of,  842 
Tenesmus  in  intussusception,  544 
Testes,  metastasis  of  mumps  to,  371 
Testicle,  retention  of,  182 
abdominal,  182 
diagnosis   of,   182 

from  hernia,  182 
double,  182 
iliac,  182 
inguinal,  182 
single,  182 
treatment  of,  182 
Tetanilla,  808 
Tetanus  antitoxin,  217 
human  milk  and,  98 
of  newborn,  214 

antitoxin   in,    217 
diagnosis  of,  216 

from  cerebrospinal  menin- 
gitis, 216 
from  traumatic  paralysis, 
216 
etiology  of,  214 
lumbar  puncture  in,  217 
pathology  of,  215 
prognosis  of,  216 
symptoms  of,  215 
treatment  of,  216 
vaccination  and,  317 
Tetany,  808 

rhvostek's  symptom  in,  811 
diagnosis  of,  812 


Tetany,  diagnosis  of,  from  convulsions 
in  infancy,  801 
etiology  of,  808 

extremities  in,  position  of,  810 
face  in,  811 
forms  of,  812 
laryngospasm  and,  812 
late,  813 
latent,  812 
mortality  of,  813 
muscular  contractures  in,  810 
parathyroid  gland  in,  809 
pathology  of,  809 
prognosis  of,  813 
puerile,  813 
sudden  death  in,  22 
symptoms  of,  810 
treatment  of,  813 
Trousseau's  phenomenon  in,  811 
Thermometer,  disinfection  of,  56,  57 
Thread-worm,  557 
Thrush,  476.     See  Sprue 
Thumb  sucking,  806 

mental  weakness  and,  806 
Thymic  asthma,  729 
Thymus  death,  729,  730,  731 

hypertrophy   of   thymus   gland 

in,  731 
lymphatism  and,  729 
treatment   of,  731 
enlargement     of,     in     laryngismus 

stridulus,  817 
gland,  abnormalities  of,  728 
abscess  of,  729 
carcinoma  of,  729 
diphtheria  and,  729 
diseases  of,  728 
hemorrhages  into,  729 
hypertrophy  of,  728 

thymus  death  in,  731 
inflammation  of,  729 
landmarks  of,  728 
lymphatism  and,  729 
percussion  of,  728 
sarcoma  of,  729 
syphilis  of,  729 
tuberculosis  of.  729 
weight  of,  728 
Thyroid  extract  in  treatment  of  cretin- 
ism, 725 
gland,  cystic  growths  of,  718 
diseases  of,  718 
enlargement  of,  718 
Tic,  831 

convulsif,  diagnosis  of,  from  chorea, 

828 
coprolalia  in,  831 
diagnosis  of,  from  chorea,  831 
echolalia  in,  831 
Titubation,  cerebral,  50 
Tongue,  congenital  anomalies  of,  484 
desquamation  of,  487 
diseases  of,  484 
geographical,  486 
ringworm  of,  486 
etiology  of,  486 


940 


INDEX. 


Tongue,  ringworm  of,  symptoms  of,  486 
treatment  of,  487 
in  scarlet  fever,  271 
strawberry,  in  scarlet  fever,  271 
wandering  rash  of,  486 
Tongue-swallowing,  487 

treatment  of,  487 
Tongue-tie,  487 

treatment  of,  487 
Tonsillitis,  catarrhal,  589 
endocarditis  and,  466 
joint-pains  and,  466 
in  scarlet  fever,  271 
ulceromembranous,  591 
diagnosis  of,  592 

from    diphtheritic    ulcers, 
592 
etiology  of,  592 
prognosis  oi,  592 
symptoms  of,  592 
treatment  of,  592 
ulcer  in,  color  of,  591 

size  of,  591 
Vincent's  bacillus  in,  592 
Tonsils,  anatomy  of,  588 
diseases  of,  588 
enlarged,  in   emphysema   of   lungs, 

602 
in  follicular  amygdalitis,  589 
herpes  of,  591 

infection  of,  enlargement  of  lymph- 
nodes  in,  715 
Top  milk,  141 

Torticollis,  position  of  head  in,  38 
Touch  sense  in  newborn,  176 
Toxic  myocarditis,  707 

stomatitis,  480 
Toxins  of  diphtheria,  380 
in  endocarditis,  691 
in  human  milk,  97,  98 
Trismus  neonatorum,  214 
Trousseau 's  phenomenon  in  laryngismus 
stridulus,  818 
in  status  lymphaticus,  730 
in  tetany,  811 

in  tuberculous  meningitis,  435 
roseola,  291.     See  Eotheln 
Tube,  nursing,  188 

Tubercle  bacillus,  scrofulosis  and,  412 
Tuberculin  tests,  424,  429 

in  tuberculous  meningitis,  442 
Tuoerculosis,  417 
of  bones,  755 

of  skull,  756 
of  brain,  443 
in  bronchiectasis,  609 
congenital.  419 

congenitally  weak  infants  and,  3  84 
contra-indication  to  maternal  nurs- 
ing, 123 
endocarditis  and,  690 
enlargement  of  lymjili-nodes  in,  715 
fibrinous  broncliitis  and,  601 
fa-tal,  419 

bacillary  form  of,  420 
characteristics  of,  420 


Tuberculosis,  foetal,   etiologj-  of,   419 
placental  infection  in,  420 
forms  of,  418 

aerogenous,  418 
alimentary,  419 
dermogenous,  419 
enterogenous,  419 
hEematogenous,  419 
lymphogenous,  419 
frequency  of,  in  childhood,  417 
general,  417 
of  heart,  432 
human  milk  and,  97.  98 
indican  in  urine  in,  33 
from  infected  cows'  milk,  105 
of  kidney,  787 
of  larynx,  432,  596 
local,  417 

of  mesenteric  glands,  431 
diagnosis  of,  431 
pathogenesis  of,  431 
prognosis  of.  432 
symptoms  of,  431 
treatment  of,  432 
pathogenesis  of,  418 
pericarditis  and,  674 
of  pericardium,  432 
of  peritoneum,  426 
acute.  426 
adhesive,  427 
chronic,  426 
course  of,  430 
diagnosis  of,  429 

from  non-tuberculous  peri- 
tonitis, 429 
from    pneumococcal    peri- 
tonitis, 572 
etiology  of,  426 
laparotomy  in,  430 
miliary,  427 
nodular,  427 
occurrence  of,  426 
pathology  of,  427 
physical  signs  of.  428 
symptoms  of,  427 
treatment  of,  430 
tuberculin  test  in.  429 
pertussis  convulsiva  and,  376 
of  pleura,  432 
portals  of  entry  of,  418 
pulmonary,  421 

bronchopneumonia  and,  422 
diagnosis  of.  424 
hfemoptysis  in,  423 
localization  of.  422 
sputum  in,  423 
symptoms  of,  422 
temperature  in,  423 
trauma  and.  423 
treatment  of,  426 
tuberculin  test  for,  424 

allergistie  reaction  in, 

426 
Calmette's,  424.  425 
conjunctival,  425 


INDEX. 


941 


Tuberculosis,  puliuoiiary,  tuberculin  test 
for,  cutaneous  scari- 
fication, 425 
methods  of,  425 
Moro  's   inunction,  424 
subcutaneous,  425 
von     Pirquet  's,     424, 

425 
Wolf -Eissner 's,      424, 
425 
scarlet  fever  and,  280 
spread  of,  modes  of,  418 
of  thymus  gland,  729 
Tuberculous  empyema,  666 

inflammation,    diagnosis    of,    from 
acute      infectious     osteomyelitis, 
758 
meningitis,  432 
pericarditis,  675 
peritonitis,  426 
acute,  569 
Tubular  nephritis,  776 
Tumefaction  in  mastoid  disease,  767 
Tumors,  adenoid,  of  umbilicus,  207 
of  brain,  840 

cerebral,  ataxic  gait  in,  50 
contour  of  abdomen  in,  44 
in  intussusception,  544 
of  larjaix,  596 
of  liver,  567 
phantom,  of  liver,  562 
polypoid,  of  umbilicus,  207 
Twitehings,  muscular,  in  chorea,  825 
Tympanic  membrane  in  otitis,  760 

resonance,  normal,  613 
Tympanites,  45,  509 

in  appendicitis,  509 
in  acute  appendicitis,  550 
in  bronchopneumonia,  637 
colic  and,  508 
liver  dulness  in,  44 
in  gastro-enteritis,  45 
in  lobar  pneumonia,  631 
in  peritonitis,  44,  509 
in  pneumonia,  45,  509 
in  rachitis,  45 
treatment  of,  509 
Tympanum,  appearance  of,  in  otitis,  764 
Typhoid  fever,  318 

abscess  in,  subcutaneous,  327 
amblyopia  in,  328 
aphasia  in,  328 
arthritis  in,  328 
ataxia  in,  328 
blood  in,  327 
blood-cultures  in,  331 
brand  bath  in,  65,  333 
bronchitis  in,  328 
bronchopneumonia     and,     326, 

639 
cholecystitis  in,  326 
complications  of,  327 
diagnosis  of,  330 

from  acute  peritonitis,  570 
from  appendicitis,  330,332 
acute,  551 


Typhoid  fever,  diagnosis  of,  from  enter- 
itis, 330 
from  cerebrospinal  menin- 
gitis, 358 
from  lobar  penumonia,  629 
from  meningitis,  330 
from  pneumonia,  330 

diet  in,  333 

diphtheria  in,  328 

duration  of,  330 

Ehrlich  diazo  reaction  in,  331 

endocarditis  and,  690 

enema  in,  73 

foetal,  319 

full  bath  in,  65 

gangrene  of  lung  in,  328 

gavage  in,  71 

headache  in,  320 

heart  in,  326 

hemorrhages  in,  325 

human  milk  and,  97,  98 

hydrotherapy  in,  333 

infantile,  319 

intestinal  perforation  in,  328 
diagnosis  of,  333 
prognosis  of,  330 
symptoms  of,  329 
treatment  of,  334 

Kernig's  symptom  in,  50 

kidneys  in,  328 

lungs  in,  326,  328 

mastoid  disease  and,  766 

mastoiditis  in,  326 

melancholia  in,  328 

mumps  and,  372 

nephritis  in,  328 

nervous  symptoms  in,  326 

occurrence  of,  318 

onset  of,  320 

onychia  in,  327 

otitis  in,  326 

pain  in,  325 

paralysis  in,  328 

parotitis  in,  326 

pathology  of,  320 

pneumonia  in,  326,  328 

pregnancy  and,  319 

prognosis  of,  332 

ptosis  in,  328 

pyuria  in,  328 

relapses  in,  327 

roseola  in,  322 

diagnosis    of,    from    mea- 
sles, 307 

sequelas  of,  327 

skin  in,  327 

spleen  in,  323 

symptoms  of,  320 

temperature  in,  324 

tongue  in,  326 

treatment  of,  332 

vomiting  in,  326 

Widal  reaction  in,  321,  331 
Typhus,  abdominal,  318 


942 


INDEX. 


Ulcer  of  stomach,  511 

of  vimbilicus,  208 
Ulcerative  endocarditis,  695 

stomatitis,  480 
Ulceromembranous  tonsillitis,  591 
Umbilical  arteries,  closure  of,  167 
cord,  52 

dressing  of,  52 
fungus  of,  53 
gangrene  of,  53 
ligation   of,   faulty,   omphalor- 
rhagia in,  211 
in  premature  infants,  52 
stump  of,  52 

drying  of,  53 
falling  off  of,  52 
tying  of,  52 
hernia,  213 
veins,  closure  of,  168 
vessels,  infection  of.  209 
Umbilicus,  adenoid  tumors  of,  207 
blennorrhoea  of.  207 

treatment  of,  208 
diseases  of,  206 
enteratomata  of,  207 
erysipelas  of.  209 
fungus  of,  207 

treatment  of,  207 
gangrene  of,  208 

treatment  of,  208 
granuloma  of,  207 
hemorrhage  from,  211 

idiopathic,  212 
hernia  of,  213.  See  Hernia,  umbilical 
infection  of,  202 
infianimation  of,  206 
phlebitis  of.  210 
phlegmon  of,  208 

treatment   of,  208 
in  pneumococcal  peritonitis,  572 
polypoid  tumors  of,  207 
seborrhoea  of,  886 
in  sepsis  in  newborn,  202,  203 
ulcer  of,  208 

treatment  of,  208 
veins  of,  inflammation  of,  210 
vessels  of,  infection  of.  209 
Uncinaria  americana,  558 
Uncinariasis,  558 

ana'mia  in,  progressive,  559 
diagnosis  of,  559 
etiology  of,  558 
prevalence  of,  558 
symptoms  of,  559 
treatment  of,  559 
Uraemia  in  .scarlet  fever,  273.  279 
Urea,  excretion  of,  by  infants,  87 
in  newborn,  173 
in  urine,  32 
Uric  acid  infarction,  34,  775 
etiology  of,  34 
in  newborn,  34 
in  newborn,  173 
in  urine,  34 


Urine,  acetone  in.  33 

in  eclampsia,  33 

in  exanthematous  fevers.  33 

in  pneumonia,  33 
albumin  in,  33 
biliary  pigment  in.  31 
in  bottle-fed  children,  31.  32 
in  breast-fed  children,  31.  32 
casts  in,  .34 
dextro.se  in.  34 
diacetic  acid  in.  33 

in    exanthematous    fevers, 
34 
examination  of.  38 
indican  in,  33 

in  artificially  fed  children,  33 

in  gastro-enteritis,  33 

in  suppurative  maladies,  33 

in  tuberculosis,  33 
in  newborn.  172 
odor  of.  31 

phvsical  characteristics  of,  31 
quantity  of.  31,  32 
in  sepsis  in  newborn,  204 
specific  gravity  of,  31 
staining:  of,  38 
urea  in,  32 
uric  acid  in.  34 
urobilin  in.  34 
Urobilin  in  urine.  34 
Urogenital  blennorrhcea,  790 
infections,  202 
tract,  diseases  of.  790 
Uvula,  bifid,  488 

malformation  of,  488 

V 

Vaccixatiox,  314 

age  and,  315 

complications  of,  316 

contra-indications  for,  315 

course  of,  316 

eczema  in,  317 

eruptions  in,  31t7 

fever  in.  316 

infection  and,  317 

lymph  for.  animal,  315 
humanized,  315 

management  of.  318 

method  of,  315 

re-vaccination,  318 

suppuration  of  joints  due  to,  317 

tetanus  and,  317 

vaccinia  in,  generalized,  317 

vesicles  of,  316 
Vaccinia,  314 

generalized,  in  vaccination,  317 
Vagina  in  sepsis  in  newborn,  203 
Valentine's  beef -juice,  115 
Valvular    anomalies    in    congenital    dis- 
ease of  heart,  687 

disease  of  heart,  chronic,  699 
Vapor  spray,  68 

in  acute  laryngitis,  68 
Varicella,  310 


INDEX. 


943 


Varicella,  bronchopBeumonia  and,  639 
complications  of,  312 
diagnosis  of,   313 
exanthema  in,  311 
gangrenosa,  312 
immunity  to,  310 
incubation  of,  310 
joints  in,  313 
mumps  and,  372 
nephritis  in,  312 
nervous  system  in,  313 
otitis  in,  313 
pneumonia  in,  313 
prognosis  of,  314 
symptoms  of,  310 
treatment  of,  311 
Vegetations,  adenoid,  579 
Vejos,  118 
Venous  hum,  706 

Ventricles,  dilatation  of,  in  septic  endo- 
carditis, 696 
hypertrophy  of,  in  congenital   dis- 
ease of  heart,  686 
Ventricular   septum,   congenital   defects 
of,  689 
cyanosis  in,  690 
murmurs  in,  690 
Vermiform  appendix,  547 
Vernix  caseosa,  53,  170 
Vertigo  in  tumor  of  brain,  841 
Vesicular  eczema,  885 

emphysema  of  lungs,  602 
Vincent 's  bacillus  in  ulceromembranous 

tonsillitis,  592 
Vision,  defective,  position  of  head  in,  40 
Vomiting  in  abscess  of  brain,  508 

in    acute    gastro-enteric    infection, 
520,  524 
peritonitis,  569 
after  eating,  507 
in  appendicitis,  507 
in  artificial  infant-feeding,  154 
cyclic,  503 

acetone  breath  in,  505 
constipation  in,  504 
diagnosis  of,  505 
etiology  of,  503 
prognosis  of,   505 
symptoms  of,  504 
urine  in,  505 
treatment  of,  505 
in  dilatation  of  stomach,  510 
habitual,  of  infants,  503 
in  infectious  diseases,  507 
in  intestinal  obstruction,  507 
in  intussusception,  543 
in  meningitis,  508 
in  mixed  infant-feeding,  132 
in  onset  of  illness,  37 
overflow,   in   mixed  infant-feeding, 

132 
periodic,  503 

in  pyloric  stenosis,  507,  513 
recurrent,  503 
stomach  washing  in.  69 
in  tumor  of  brain,  50S.  841 


Vomiting,  uncontrollable,  74 

Von  Jaksch's  disease,  739 

Von  Pirquet's  tuberculin  test,  424,  425 

Vulvovaginitis,  790 

arthritis  and,  792 

complications  of,  791 

conjunctivitis  and,  792 
Vulva,  diphtheria  of,  392 

etiology  of,  790 

gonococci  in,  791 

occurrence  of,  790 

peritonitis  and,  791 

prophylaxis  of,  792 

symptoms,  791 

treatment  of,  792 

W 

Walking,  development  of,  35 
Wandering  rash  of  tongue,  486 
Water,    administration    of,    in    gastro- 
enteritis, 83 

in  cows'  milk,  102 

excretion  of,  by  infants,  88 
in  human  milk,  82 

percentage  of,  82 

role  of,  in  nutrition,  82 
Weaning,  160,  161 

artificial  infant  foods,  at  time  of, 

121,  122 
difficulties  in,  xoO 
time  of,  160 

Weight,  average,  24  25 
chart  of,  24 
increase  of,  25 

in  bottle-fed  children,  25,  150 
in  breast-fed  children,  25 
daily,  25,  26 
loss  of,  following  birth,  24 
Werlhof 's  disease,  749 
Wet-nurse,  age  of,  125 
breast  of,  125 
examination  of,  125 

baby  of,  125 
milk  of,  nail-test  for,  126 
quality  of,  126 
quantity  of,  126 
nipples  of,  125 
selectio'    ^r,  125 
Wet-nursing,  objections  to,  122,  123 

transmission    of    diathesis   through, 

122,  123 

Whey,   in   artificial  infant-feeding,   156 
composition  of,  155 
laboratory   combinations,   table   of, 

157 
preparation  of,  155,  156 
proteids  in  human  milk,  91,  92 
White  blood-cells,  735 
Whooping-cough,  372 
Widal   reaction   in   typhoid  fever,   321, 

331 
Winckel's  disease,  222 

diagnosis  of,  223 

from    acute    fatty    degen- 
eration of  newborn,  223 


944 


IXDEX. 


Winckel's    disease,    diagnosis    of,   from 
BuM's  disease,  223 
etiology  of,  223 
hemorrhages  in,  219,  223 
pathology  of,  223 
prognosis  of,  223 
in  sepsis  in  newborn,  201 
symptoms  of,  223 
treatment  of,  223 
Woodward's   method   of    estimation    of 
proteids,  102 
milk  burette,  102 
Wool,  clothing,  61 
Wolf -Eissner 's  tuberculin  test,  424,  425 


Worm,  hook-,  558 

intestinal,  555 

pin-,  557 

round,  556 

tape-,  557 

thread-,  557 
Wound  infection  with  scarlet  fever,  270 
Wrist-drop  in  chorea.  825 

in  multiple  neuritis,  855 
Wyeth 's  beef -juice,  115 


Yelloav  atrophy  of  liver,  acute,  56  < 


DATE  DUE 

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